diff --git "a/train_file_mt.csv" "b/train_file_mt.csv" new file mode 100644--- /dev/null +++ "b/train_file_mt.csv" @@ -0,0 +1,12022 @@ +Unnamed: 0,description,medical_specialty +12277,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +12576,Is it BNP or BMP?,19 +9140,Autopsy of a white female who died of acute combined drug intoxication.,1 +6707,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +7246,A sample note on Rheumatoid Arthritis,34 +12448,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +889, The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,16 +10072,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +7791,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +6181,"Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",21 +1391," Patient was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. ",5 +1778," Toenails are discolored, thickened, and painful - Onychomycosis",5 +9319,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +5543,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +3702, Common Excretory Urogram - IVP template,39 +9565,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +9831,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11476,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5454,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +8285,The case was referred for evaluation of cataracts bilaterally,20 +10700,Dietary consultation for diabetes during pregnancy.,9 +3926," Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",38 +2097, Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +248, Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.,38 +10409,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +4057,"Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 +6048,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +1814, A 53-year-old female with left knee pain being evaluated for ACL tear.,33 +2351, Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,3 +2947," Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.",35 +8512,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +12258,A sample note on Rheumatoid Arthritis,34 +7870,Dietary consultation for gestational diabetes.,9 +11660,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +7956,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +8100,Occupational medicine consult with questions-answers and records review.,18 +6862,"Onychomycosis present, #1 right and #1 left.",31 +2612, Nephrology Consultation - Patient with renal failure.,21 +10474,Work restrictions and disability evaluation,4 +12510,Elevated cholesterol and is on medication to lower it.,9 +9647,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10086,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +5553,"Sample normal ear, nose, mouth, and throat exam.",11 +1321," Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.",14 +977, Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,24 +6474,Normal child physical exam template.,29 +9377,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2219," Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +2755," Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.",14 +4680,"Still having diarrhea, decreased appetite.",35 +2470, Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,3 +10015,Follow up update on case with left carotid angioplasty and stent placement.,20 +7104,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +6151,"The patient has had abdominal ache associated with a 30-pound weight loss and then developed jaundice. He had epigastric ache and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.",10 +6555,Cause of death - Anoxic Encephalopathy,1 +5370,Ultrasound OB - followup for fetal growth.,24 +12122,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +12560,A 23-year-old white female presents with complaint of allergies.,0 +6051,"Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",26 +4950,Knee injection,28 +7063,"Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",31 +632, Dietary consultation for carbohydrate counting for type I diabetes.,5 +1150," EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.",14 +9842,A 23-year-old white female presents with complaint of allergies.,0 +3161," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",38 +8682,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +6043,"Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",23 +4587,"Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 +1881, Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. ,37 +10509,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +6643,"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +10410,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +10960,Patient presents for therapy of suspected rheumatoid arthritis.,34 +4051,"Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +3375," Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",31 +10358,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +5988,Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 +2126, Asked to see the patient in regards to a brain tumor. She was initially diagnosed with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. ,5 +8876,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +634," Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.",38 +12582,Is it BNP or BMP?,19 +9794,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8271,Incision and drainage of right buccal space abscess and teeth extraction.,7 +6704,Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 +10563,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +9336,Elevated cholesterol and is on medication to lower it.,9 +1208, Patient complains of constipation. Has not had BM for two days.,14 +1457," Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.",27 +9294,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5431,Emergency cesarean section.,24 +2753, CT Scan of brain without contrast.,22 +7394,Chiropractic IME with answers to questions from Insurance Company.,4 +4841,"Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",22 +118, Diagnosis of benign rolandic epilepsy.,22 +5005,"He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",35 +3015, Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,27 +9176,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +8004,The case underwent an overnight polysomnogram.,36 +6731,Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,23 +10497,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +923," Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",5 +8366,"The case with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +9198,Consultation for wrist pain.,4 +10603,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +4638,Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,11 +3173, The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. ,11 +7195,Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,32 +10680,Dietary consultation for gestational diabetes.,9 +1383, Vitrectomy under general anesthesia,38 +11182,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +10564,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10973,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6477,Evaluation for chronic ache program,4 +9441,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +1628, MRI Head W&WO Contrast.,33 +2653, Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. ,38 +191, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,3 +11601,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +775," Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",21 +5846,"Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 +8778,Dietary consultation for gestational diabetes.,9 +8343,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +767, Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 +8913,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +7821,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +2046, Psychiatric Consultation of patient with major depression disorder.,5 +11135,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7861,Occupational medicine consult with questions-answers.,18 +7165,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +12565,A 23-year-old white female presents with complaint of allergies.,0 +7213,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11424,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +244, Patient with episode of lightheadedness and suddenly experienced vertigo.,5 +693," Follow up consultation, second opinion, foreskin.",39 +887," Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease.",3 +4828,"Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative clinical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",24 +8839,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +3066, Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,23 +8462,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +7024,Sample/template for a normal male multisystem exam.,25 +4407,"Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.",33 +11205,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +5290,"Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.",28 +11110,Patient presents for care of suspected rheumatoid arthritis.,34 +10083,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +11516,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +8801,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +4449,Bilateral renal ultrasound.,21 +6756,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +6831,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +8159,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +9435,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2459," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +8852,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +1098," Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",5 +5222,Adenotonsillectomy. Adenotonsillitis with hypertrophy. The case is a very nice case with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +1," Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.",3 +4431,Newly diagnosed head and neck cancer. The case was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 +309, Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,38 +11301,Occupational medicine consult with questions-answers and records review.,18 +5731,"Right hand laceration x3, repaired.",25 +3018," Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",15 +8880,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +2078," Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.",5 +7532,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5179,"Left flank pain, ureteral stone.",39 +2766, Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +10190,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +5876,Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 +27, Bilateral Myringotomy with placement of PE tubes,11 +12313,Patient presents for care of suspected rheumatoid arthritis.,34 +9382,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3013, Revision and in situ pinning of the right hip.,38 +6629,Excisional biopsy of right cervical lymph node.,16 +1159," Fever, otitis media, and possible sepsis.",29 +8352,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +871," General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ",15 +515," Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",26 +8083,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +1597, MRI L-Spine - Bilateral lower extremity numbness,27 +744, Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,38 +7711,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +4296,"The case is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 +4598,"Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.",22 +2887," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +8792,Is it BNP or BMP?,19 +11582,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3212," Acute appendicitis, gangrenous. Appendectomy.",14 +7980,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +11626,Dietary consultation for gestational diabetes.,9 +7620,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +10149,"Specimen labeled ""sesamoid bone left foot"".",19 +5570,"Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 +7675,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11743,Autopsy of a white female who died of acute combined drug intoxication.,1 +12383,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +5774,The client was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.,32 +3352," Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 +9534,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +2910, Incision and drainage of left neck abscess.,38 +3258, Headache. Right frontal lobe glioma.,22 +8705,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +2889," Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.",22 +9398,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3483, CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization.,22 +2322, She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,26 +9864,Dietary consultation for gestational diabetes.,9 +7581,Is it BNP or BMP?,19 +9236,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +5616,Normal vasectomy,39 +4231,Sample progress note - Gen Med.,15 +110, Patient with intermittent episodes of severe nausea and abdominal pain.,15 +7458,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +11405,Preop evaluation regarding gastric bypass surgery.,2 +6613,"Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",21 +9873,Dietary consultation for diabetes during pregnancy.,9 +1965, Right upper lung lobectomy. Mediastinal lymph node dissection,3 +1241," Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.",14 +2848," Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",21 +2364, Sore throat - Upper respiratory infection.,15 +915," Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",38 +2795," Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.",38 +5978,"Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",10 +10663,Evaluation for bariatric surgery.,2 +8047,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +4314,"Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",16 +3667," A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.",5 +4916,Right orchiopexy and right inguinal hernia repair.,39 +4126,"Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",35 +2384, MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,27 +10072,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +8798,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +8638,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5762,Consultation for evaluation of thrombocytopenia.,16 +1958, Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +6497,"CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",21 +10575,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3388, A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,15 +1607, Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.,38 +11696,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7626,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6514,"Evaluate for retroperitoneal hematoma, the client has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",21 +6029,Urgent cardiac catheterization with coronary angiogram.,12 +9064,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +7416,Is it BNP or BMP?,19 +9106,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +6924,Complete heart block with pacemaker malfunction and a history of Shone complex.,12 +8873,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +7108,Bender-Gestalt Neurological Battery and Beck testing.,32 +1526, The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,3 +7544,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9264,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2048," Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.",27 +2423, Scleral Buckle opening under general anesthesia.,26 +2876," Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.",38 +8744,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +3541, Chronic headaches and pulsatile tinnitus.,11 +1035," This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. ",5 +470, This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,22 +612, Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,14 +11014,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6020,Costochondral Cartilage Injection,28 +11785,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +802, Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,27 +1075, Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,5 +9795,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7790,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +113," Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +10876,Cause of death - Anoxic Encephalopathy,1 +3741," CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",38 +2545," Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.",27 +5606,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +1826," Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",33 +1425," Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.",3 +12040,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +974," Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",24 +3553, Ultrasound Abdomen - elevated liver function tests.,14 +2046, Psychiatric Consultation of patient with major depression disorder.,5 +11795,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4823,A white female presents for exam and Pap.,24 +8429,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7413,Dietary consultation for gestational diabetes.,9 +10070,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +365, Right basilic vein transposition. End-stage renal disease with need for a long-term hemodialysis access. Excellent flow through fistula following the procedure.,38 +11039,Mother states he has been wheezing and coughing.,0 +12572,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9958,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +1309," Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",22 +10916,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3331, Plantar Fascia Injection,28 +2770, Circumcision procedure (neotal),38 +4120,Closure of gastrostomy placed due to feeding difficulties.,14 +8046,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +4122,"The client was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +10024,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +10998,A 23-year-old white female presents with complaint of allergies.,0 +1943," Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",38 +9592,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4150,LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,24 +4030,"Complex regional discomfort syndrome, right upper extremity. Stellate ganglion block.",28 +6220,Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique.,28 +3507," Patient with several medical problems - numbness, tingling, and a pain in the toes.",15 +8919,"Specimen labeled ""sesamoid bone left foot"".",19 +3452, Patient with a 1-year history of progressive anterograde amnesia,5 +1376," Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.",3 +1392," Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.",38 +8113,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +8765,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +4216,"2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",15 +482, Patient with a long history of depression and attention deficits.,32 +10921,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4503,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +6703,Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 +8781,Dietary consultation for gestational diabetes.,9 +398," Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.",3 +1945, Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,16 +4810,Injection of Morton's neuroma.,28 +1732, Laparoscopic appendectomy. Acute appendicitis.,14 +10660,Work restrictions and disability evaluation,18 +1702, Right upper lung lobectomy. Mediastinal lymph node dissection,38 +12520,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11390,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +11986,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +581, This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,33 +5526,"Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",29 +12081,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +10640,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +566," Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.",38 +2692," Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.",3 +8887,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +1238," New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.",5 +10130,Patient referred for narrow angles and possible associated glaucoma.,20 +836, Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.,38 +278," Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",5 +12079,Cause of death - Anoxic Encephalopathy,1 +10296,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +10122,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +11885,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +4496,Right distal ureteral calculus. The client had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.,39 +942, Inguinal hernia hydrocele repair.,38 +6301,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +3946," Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.",16 +12596,Mother states he has been wheezing and coughing.,0 +12557,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9667,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3217, 2-month-old female - increased work of breathing.,3 +4730,A sample note on Cataract,26 +10468,Work restrictions and disability evaluation,4 +4955,Vitrectomy under local anesthesia.,26 +7483,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +341," Sample normal ear, nose, mouth, and throat exam.",5 +4401,The client is admitted with a diagnosis of acute on chronic renal insufficiency.,21 +3068, Phacoemulsification with posterior chamber intraocular lens insertion.,26 +2299," Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure.",24 +1991," Intercostal block, left. Severe post thoracotomy pain.",28 +280, Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 +5514,An example/template for a routine normal male ROS.,25 +5325,Cystoscopy. Transurethral resection of the prostate.,39 +2490, A 10 years of age carries a diagnosis of cystic fibrosis,5 +2583, Patient today with ongoing issues with diabetic control.,13 +5670,"The case had hematuria, and unable to void. The case had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.",39 +9944,Occupational medicine consult with questions-answers and records review.,18 +12067,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +5334,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,12 +1742, Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,38 +1895, Common CT Chest template,33 +789," Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.",14 +1267, Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,35 +2135, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,38 +5115,Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,32 +1616, Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,27 +11314,Dietary consultation for diabetes during pregnancy.,9 +9798,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +1432, Patient with right ankle pain.,27 +1524," Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",38 +5448,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,16 +3253," Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",24 +10861,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +7711,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1819, Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,14 +3641, Inguinal hernia hydrocele repair.,39 +6069,Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,10 +1106, This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,33 +10507,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +1793," General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, ",35 +10491,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10622,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1323, The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,27 +7862,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +8106,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +3880," Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",33 +1307, Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,3 +9737,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9575,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5800,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +2774," Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.",33 +12320,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9837,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6665,Belly button piercing for insertion of belly button ring.,6 +11524,Qualified medical evaluation report of a client with back pain.,4 +11415,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +3876, Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. ,33 +4674,"Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 +3960," Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",26 +5545,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +6163,Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated.,28 +1382, Endoscopic release of left transverse carpal ligament.,38 +11589,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +453," Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.",27 +4343,"Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.",14 +140, Patient with episode of lightheadedness and suddenly experienced vertigo.,22 +7153,Patient dropped a weight on the dorsal aspects of his feet.,12 +7659,Patient presents for therapy of suspected rheumatoid arthritis.,34 +4848,Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.,24 +3371," 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.",38 +10900,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +7134,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.",31 +2154," Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",38 +7413,Dietary consultation for gestational diabetes.,9 +2466," Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.",5 +10818,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +9584,Autopsy - Asphyxia due to ligature strangulation.,1 +11948,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12424,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +11193,Occupational medicine consult with questions-answers and records review.,18 +6690,"A 7-year-old white male started to complain of discomfort in his fingers, elbows, and neck. This patient may have had reactive arthritis.",29 +11031,Mother states he has been wheezing and coughing.,0 +1914, A 5-month-old boy brought by his parents because of 2 days of cough. ,5 +7762,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +4489,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +3002," He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ",20 +8459,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +2780," Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",5 +7634,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9608,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5295,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",10 +10429,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +9851,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +10871,Cause of death - Anoxic Encephalopathy,1 +11520,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8354,Qualified clinical evaluation report of a patient with back pain.,4 +10793,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +8609,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +3144, Electroencephalographic findings and interpretation,22 +10672,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +85," Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.",38 +3897," Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",23 +6950,"Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 +6838,"Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the case ended up taking a total of six Ecstasy tablets.",12 +2676, Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. ,5 +12594,Mother states he has been wheezing and coughing.,0 +6787,Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib discomfort related to a herniated nucleus pulposus at T8-T9.,23 +12555,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2269," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",22 +4435,Upper endoscopy with foreign body removal (Penny in proximal esophagus).,14 +11173,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6272,An example/template for a routine normal male physical exam.,25 +4509,"Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 +11883,Patient presents for care of suspected rheumatoid arthritis.,34 +8234,Patient scheduled for laparoscopic gastric bypass.,2 +1223," Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",38 +4317,Whole body radionuclide bone scan due to prostate cancer.,33 +6914,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",29 +5356,"Cystoscopy, cryosurgical ablation of the prostate.",39 +10534,Occupational medicine consult with questions-answers and records review.,18 +11995,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no discomfort that radiates from her back into her legs. She has had no associated weakness.",30 +11269,A 23-year-old white female presents with complaint of allergies.,0 +2540, General Medicine SOAP note.,35 +2682," Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",11 +10175,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +1525, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,5 +7301,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10617,Chiropractic IME with answers to questions from Insurance Company.,4 +3613," Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. ",3 +4487,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +11513,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +3919, Repeat cesarean section and bilateral tubal ligation.,38 +4783,The client was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,32 +7509,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6315,Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 +10819,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +4310,"Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 +1985, Left heart cardiac catheterization.,38 +8596,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +7699,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3680," Malignant mass of the left neck, squamous cell carcinoma. Left neck mass biopsy and selective surgical neck dissection, left.",38 +8260,Acne with folliculitis.,8 +7211,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3503," Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",21 +9537,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10906,Dietary consultation for carbohydrate counting for type I diabetes.,9 +3840, 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.,15 +7834,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +571, MRI C-spine: C4-5 Transverse Myelitis.,22 +1602," Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.",27 +9545,Cause of death - Anoxic Encephalopathy,1 +1972," Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.",38 +3826, Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation. ,14 +10414,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +9552,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7472,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +5731,"Right hand laceration x3, repaired.",25 +9390,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10146,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +9346,Patient presents for therapy of suspected rheumatoid arthritis.,34 +9738,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7018,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +527, Coronary Artery CTA with Calcium Scoring and Cardiac Function,3 +8561,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +11643,Dietary consultation for diabetes during pregnancy.,9 +4481,Esophagogastroduodenoscopy and colonoscopy with polypectomy,14 +3238," Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",38 +4165,The client is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 +4123,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +1754," Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",27 +5142,Work restrictions and disability evaluation,18 +7785,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +5858,Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 +12292,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10268,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +9138,Autopsy of a white female who died of acute combined drug intoxication.,1 +712," This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ",22 +3250," Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.",38 +10912,Dietary consultation for carbohydrate counting for type I diabetes.,9 +391," Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",23 +12121,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6040,Generalized abdominal discomfort with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,21 +65, 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.,38 +10031,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +6586,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +4464,Patient in ER with upper respiratory infection,12 +11410,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +1420," Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",15 +9696,A sample note on Rheumatoid Arthritis,34 +7781,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +7257,Autopsy of a white female who died of acute combined drug intoxication.,1 +1864," Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",24 +11149,A sample note on Rheumatoid Arthritis,34 +1358," Left heart catheterization, left ventriculography, selective coronary angiography.",38 +10925,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8896,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +9214,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +12004,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +12158,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +8176,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +12229,Mother states he has been wheezing and coughing.,0 +12054,Preop evaluation regarding gastric bypass surgery.,2 +2897," Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",21 +10006,Incision and drainage (I&D) of buttock abscess.,8 +9968,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3503," Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",21 +7597,Mother states he has been wheezing and coughing.,0 +9280,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +2262," Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 +6357,"Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 +12580,Is it BNP or BMP?,19 +9830,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +8763,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +4748,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +10471,Work restrictions and disability evaluation,4 +11407,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12224,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +8165,Preoperative visit for weight management with laparoscopic gastric banding,2 +255, Bilateral scrotal orchiectomy,38 +11303,Occupational medicine consult with questions-answers and records review.,18 +2283, MRI Orbit/Face/Neck with MR Angiography of the Head - An infant with facial mass,33 +2201," Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.",38 +8686,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +9988,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +2000, Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +3707, The patient with a recent change in bowel function and hematochezia.,38 +10937,Autopsy - Asphyxia due to ligature strangulation.,1 +7030,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +3979, Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,38 +6080,"Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",10 +8828,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +5228,"Head injury, anxiety, and hypertensive emergency.",29 +2608, Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.,3 +11549,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +72," Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use.",38 +776, Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.,3 +9347,Patient presents for therapy of suspected rheumatoid arthritis.,34 +8460,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +6659,Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 +11019,Is it BNP or BMP?,19 +7928,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +4170,Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.,10 +7492,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8701,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +5112,"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 +7228,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10113,"Patient suffers from neck and lower back ache radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +5199,Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,24 +3229," Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",27 +7955,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +1067, Is it BNP or BMP?,19 +8121,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +9174,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +4385,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 +11821,Patient presents for therapy of suspected rheumatoid arthritis.,34 +194," Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.",27 +5395,Patient complains of chest discomfort - possible esophageal reflux,12 +3092, Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 +2338, Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,38 +11286,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +5166,"Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",39 +1923, Invasive carcinoma of left breast. Left modified radical mastectomy.,24 +6327,Scleral Buckle opening under general anesthesia.,26 +11490,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +6539,"Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye",26 +2626," Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.",38 +7814,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +11646,Dietary consultation for diabetes during pregnancy.,9 +972," Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.",3 +7680,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +852," Nonhealing right ankle stasis ulcer. A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. ",5 +2846," Primary cesarean section by low-transverse incision. Term pregnancy, nonreassuring fetal heart tracing.",38 +7008,The case was referred for evaluation of cataracts bilaterally,20 +5221,Adenotonsillectomy. Adenotonsillitis with hypertrophy. The client is a very nice client with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +1145," Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ",24 +8963,Mother states he has been wheezing and coughing.,0 +3678, Consultation for right shoulder pain.,5 +3825, Normal vasectomy,38 +5633,"Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 +3345, Incision and drainage of right buccal space abscess and teeth extraction.,7 +10646,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +4500,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +7874,Is it BNP or BMP?,19 +4166,The client is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 +1053, Dietary consultation for gestational diabetes.,5 +12047,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +4246,Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal.,14 +11828,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10790,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +791," Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.",38 +5427,The case was referred due to concerns regarding behavioral acting out as well as encopresis.,32 +9845,A 23-year-old white female presents with complaint of allergies.,0 +3493, Right orchiopexy and right inguinal hernia repair.,38 +2329, Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,5 +6109,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +9182,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +4195,Procedure note on Keller Bunionectomy,31 +3622," CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",33 +3245, CT Brain: Midbrain hemangioma,22 +300, Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 +3233," Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",29 +12374,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4791,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +1961," Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",12 +1159," Fever, otitis media, and possible sepsis.",29 +8859,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +158," The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",32 +10685,Is it BNP or BMP?,19 +3383," Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.",38 +4029,"Complex regional ache syndrome, right upper extremity. Stellate ganglion block.",28 +10105,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +6191,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 +6585,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +1281, Common Excretory Urogram - IVP template,33 +12452,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +5107,The case was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,16 +4079,MRI Cervical Spine without contrast.,33 +4536,Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,14 +8541,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7399,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +9362,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6402,"Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The client is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.",23 +8909,"Followup diabetes mellitus, type 1.",13 +5710,"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.",23 +1100, MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,33 +2425," Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",35 +9543,Cause of death - Anoxic Encephalopathy,1 +11732,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +7402,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +1899," Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +4354,Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,23 +3763," Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",24 +2471," Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",38 +5684,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +11079,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8133,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +11435,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +8940,Chiropractic IME with answers to questions from Insurance Company.,18 +4218,External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 +559," Hypomastia. Patient wants breast augmentation and liposuction of her abdomen, ",6 +12172,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12026,Autopsy - Homicide - Blunt force cranial trauma,1 +5512,Discharge summary of a case with depression and high risk behavior.,10 +11005,A 23-year-old white female presents with complaint of allergies.,0 +997, Laparoscopic left inguinal hernia repair.,38 +41, Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips.,38 +11773,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1487, Left partial nephrectomy due to left renal mass.,38 +5476,"Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.",24 +3161," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",38 +886," Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).",38 +6253,Status post cadaveric kidney transplant with stable function.,21 +465, Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,38 +3190, Carotid artery angiograms.,3 +2229," Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.",3 +7449,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +3079, Stress test with Bruce protocol due to chest pain.,3 +12635,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6590,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 +2979, MRI left knee.,27 +2965, Sample/template for a normal female multisystem exam,25 +264," Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",3 +12296,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5065,Ophthalmology followup visit note.,26 +12554,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1956," Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder.",38 +10960,Patient presents for therapy of suspected rheumatoid arthritis.,34 +2203, Common description of EGD.,38 +1873," History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy.",14 +3118," Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.",14 +3171," Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ",8 +6430,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 +6504,"Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",11 +5696,Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy.,16 +4524,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8296,Diagnosis of benign rolandic epilepsy.,20 +5310,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 +16," Complex regional pain syndrome, right upper extremity. Stellate ganglion block.",28 +3128, Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins.,38 +4152,Normal upper GI endoscopy.,14 +9132,Consult for laparoscopic gastric bypass.,2 +10915,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4541,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",35 +11193,Occupational medicine consult with questions-answers and records review.,18 +10876,Cause of death - Anoxic Encephalopathy,1 +6466,"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.",26 +189, Whole body radionuclide bone scan due to prostate cancer.,33 +2184, Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. ,28 +1401," Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",21 +12217,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +7780,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +6176,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +2019, Patient status post lap band placement.,35 +2088, A female with unknown gestational age who presents to the ED after a suicide attempt.,24 +11161,A sample note on Rheumatoid Arthritis,34 +4240,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",15 +3949, Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.,38 +10782,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +8399,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11363,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +456," Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",5 +9002,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +8861,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10090,Occupational medicine consult with questions-answers and records review.,18 +8362,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +8613,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +9405,A 23-year-old white female presents with complaint of allergies.,0 +1366," Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.",38 +7818,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +550," Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +5718,The client seeks evaluation for a second opinion concerning cataract extraction.,26 +3180, Patient with history of polyps.,38 +12577,Is it BNP or BMP?,19 +1531, CT REPORT - Soft Tissue Neck,33 +10913,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2842," Specimen labeled ""sesamoid bone left foot"".",27 +10556,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4297,"The case is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 +7250,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3164, Implantation of a dual chamber permanent pacemaker,38 +12398,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +11428,Occupational medicine consult with questions-answers and records review.,18 +3219, Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. ,26 +5350,"Pain and swelling in the right foot, peroneal tendon tear.",31 +9427,Is it BNP or BMP?,19 +6277,"Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",31 +5843,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8092,Autopsy of a white female who died of acute combined drug intoxication.,1 +3430," 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.",23 +10389,"The case is a 26-year-old female, referred to Physical Therapy for low back pain. The case has a history of traumatic injury to low back.",30 +3052," A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.",3 +3964, Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,14 +6919,"Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming determination of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.",12 +9692,A sample note on Rheumatoid Arthritis,34 +1707, Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,38 +3819, Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,27 +7141,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 +8510,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +10270,Consult for laparoscopic gastric bypass.,2 +5209,Occupational medicine consult with questions-answers.,18 +10766,Autopsy - Homicide - Blunt force cranial trauma,1 +7605,Autopsy - Homicide - Blunt force cranial trauma,1 +6585,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +7291,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +596, Transesophageal echocardiogram and direct current cardioversion.,3 +2402," Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",12 +2605, The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. ,15 +9762,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7087,"Sample normal ear, nose, mouth, and throat exam.",25 +8764,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +11013,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11864,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2574, Well-child check and school physical.,5 +7023,An example/template for a routine normal female physical exam.,25 +8194,"Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 +10321,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +9222,Cause of death - Anoxic Encephalopathy,1 +9708,A sample note on Rheumatoid Arthritis,34 +4032,"Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.",23 +12472,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +2502, Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,17 +4457,Sample Radiology report of knee (growth arrest lines).,33 +11387,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +827, Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.,27 +7918,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +7427,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +4802,"Creation of AV fistula, left wrist in the anatomic snuffbox.",21 +3675, Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 +3942, Diagnosis of bulbar cerebral palsy and hypotonia. ,20 +10637,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +5703,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +8956,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +6446,Patient today with ongoing issues with diabetic control.,13 +12611,A sample note on Rheumatoid Arthritis,34 +12138,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3377," 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.",38 +408," A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.",12 +3261, Laparoscopic appendectomy. Acute appendicitis.,14 +10804,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +12569,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5802,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +70, Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +3943, A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,10 +8735,Evaluation for bariatric surgery.,2 +3817," Desire for sterility. Vasectomy. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.",38 +723," Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",27 +1426," Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.",3 +3892, Circumcision and release of ventral chordee.,38 +9662,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6799,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",31 +5121,A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 +9359,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +12172,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10499,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +6354,"Normal review of systems template. The client denies fever, fatigue, weakness, weight gain or weight loss.",25 +6308,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +3938, Vaginal discharge with a foul odor.,12 +6383,"Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",21 +5351,"Pain and swelling in the right foot, peroneal tendon tear.",31 +25," Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 +4221,"Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",39 +10994,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9755,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8054,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +9494,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +7265,Cause of death - Anoxic Encephalopathy,1 +2958," A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.",5 +11886,Work restrictions and disability evaluation,4 +8554,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +4214,A 60-year-old female presents today for care of painful calluses and benign lesions.,35 +1430," Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.",38 +5871,A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.,16 +7229,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9234,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +454," Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.",23 +7231,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +2890, Primary low segment cesarean section.,38 +4072,Primary low-transverse cesarean section.,24 +2493," Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.",3 +9591,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6122,"Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",21 +7577,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7242,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +6515,"Evaluate for retroperitoneal hematoma, the case has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",21 +7552,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11009,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6961,Bilateral myringotomy tubes and adenoidectomy.,11 +5477,Trauma/ATV accident resulting in left open humerus fracture.,10 +7150,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12654,Patient presents for care of suspected rheumatoid arthritis.,34 +2472," Creation of AV fistula, left wrist in the anatomic snuffbox.",38 +4986,Consultation for ICU management for a client with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 +12055,Preop evaluation regarding gastric bypass surgery.,2 +9562,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +5712,"The client is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",32 +141," Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",27 +12429,"Specimen labeled ""sesamoid bone left foot"".",19 +4551,An example/template for a routine normal male physical exam.,25 +5927,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,12 +9672,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10962,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9505,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +11022,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6480,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +2886," Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.",27 +9018,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +3620, Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,23 +926," Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.",38 +925, A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.,15 +8590,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +3409," Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.",38 +11793,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7113,Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,26 +11588,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1317," Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ",27 +8118,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +707, Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,5 +3917, The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.,27 +5097,Urine leaked around the ostomy site for his right sided nephrostomy tube. The client had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 +7135,Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 +5404,"Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",21 +8439,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +7260,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7138,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +3330, Psychiatric History and Physical - Patient with major depression,5 +4582,"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",29 +859, Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +10510,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +4125,"Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",35 +11297,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +4754,"Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.",28 +4926,"Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",31 +1977, Ultrasound-Guided Paracentesis for Ascites,14 +10350,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The case fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +11403,Preop evaluation regarding gastric bypass surgery.,2 +2543," 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. ",5 +11177,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +9488,A sample note on Rheumatoid Arthritis,34 +1237, Dietary consultation for diabetes during pregnancy.,9 +603, An example/template for a routine normal male physical exam.,15 +4806,Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.,22 +2446, Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.,5 +10837,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +1788, Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum. ,14 +856, MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.,22 +7041,"Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 +5635,"Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 +10107,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2027," Sterilization candidate. Cervical dilatation and laparoscopic bilateral partial salpingectomy. A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.",24 +7038,Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +1580," The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",32 +1144," Total abdominal hysterectomy. Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis. On laparotomy, the uterus did have multiple pedunculated fibroids.",38 +9087,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3997, Repair of bilateral cleft of the palate with vomer flaps.,11 +3725," Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.",3 +3393," Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",27 +12355,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +8275,Chronic snoring in children,36 +11471,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +10696,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7575,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +760, Initial evaulation - neck and back pain.,27 +12524,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10158,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +4566,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent determination of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +3426, Bilateral myringotomy tubes and adenoidectomy.,11 +7607,A sample note on Rheumatoid Arthritis,34 +9197,Consultation for wrist pain.,4 +4213,A 60-year-old female presents today for care of painful calluses and benign lesions.,35 +2261," Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.",5 +7982,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +4855,"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 +10277,Autopsy of a white female who died of acute combined drug intoxication.,1 +4872,Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 +5242,Psychosocial Evaluation of client before kidney transplant.,21 +10157,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +8299,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +3458, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,27 +12229,Mother states he has been wheezing and coughing.,0 +1047," Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 +2945, Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.,5 +8723,Work restrictions and disability evaluation,18 +3894, Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. ,23 +10631,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +9364,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11450,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +11940,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +10567,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +792," Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.",38 +11246,Chiropractic IME with answers to questions from Insurance Company.,4 +11174,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1336, Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,23 +7066,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 +367, 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.,38 +5914,"Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.",10 +2664, Preoperative visit for weight management with laparoscopic gastric banding,2 +6575,Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,23 +4802,"Creation of AV fistula, left wrist in the anatomic snuffbox.",21 +10053,The client is being referred for evaluation of diabetic retinopathy.,20 +10450,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent clinical evaluation.,18 +5372,Ultrasound OB - followup for fetal growth.,24 +3225," Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.",27 +1258," Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",27 +10362,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +8242,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +537," Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ",38 +574," Right open carpal tunnel release and cortisone injection, left carpal tunnel.",27 +7879,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +9776,Patient presents for care of suspected rheumatoid arthritis.,34 +10933,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4587,"Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 +7479,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +3491, Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. ,38 +2094," Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy. +",38 +7984,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +5390,"Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",23 +111," This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.",5 +11224,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +5255,"Clogged AV shunt. The client complains of fatigue, nausea, vomiting and fever.",21 +4412,Patient in ER due to colostomy failure - bowel obstruction.,14 +10634,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +6193,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 +9251,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +11679,"Specimen labeled ""sesamoid bone left foot"".",19 +9395,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6185,"Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 +4379,"Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The case appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",24 +312," Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",26 +8962,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +12206,Is it BNP or BMP?,19 +7116,"Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.",28 +8676,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +9349,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6285,Occupational medicine consult with questions-answers and records review.,18 +6009,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",12 +9847,A 23-year-old white female presents with complaint of allergies.,0 +5855,Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.,26 +7932,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +8540,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4414,Patient in ER due to colostomy failure - bowel obstruction.,14 +1574, MRI cervical spine.,33 +2712, Examination due to blood-borne pathogen exposure.,5 +4550,An example/template for a routine normal male physical exam.,25 +10218,Letter to the case to let him know about his abnormal cholesterol test results.,20 +8467,Occupational medicine consult with questions-answers and records review.,18 +5673,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +8070,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7767,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +6370,Migraine headache - The case was seen in the urgent care.,12 +2114, Dobutrex stress test for abnormal EKG,33 +12600,Autopsy - Homicide - Blunt force cranial trauma,1 +2076," Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.",5 +10957,Patient presents for care of suspected rheumatoid arthritis.,34 +1861, Patient presents with complaint of lump in the upper outer quadrant of the right breast,5 +6669,Psychiatric consultation for alcohol withdrawal and dependance.,32 +3187, The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. ,26 +6177,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +5396,Patient complains of chest discomfort - possible esophageal reflux,12 +929," The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.",5 +3311, Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,38 +7151,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5738,"The client comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.",32 +8332,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9687,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3231," Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",11 +1048, Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,38 +9553,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6949,"Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 +11422,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +9919,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8901,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +9204,Evaluation for chronic ache program,4 +408," A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.",12 +1389, Endoscopic proximal shunt revision.,23 +3313, Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,38 +10439,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +5460,Dietary consultation for diabetes during pregnancy.,9 +6746,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 +5542,Psychiatric consultation for substance abuse.,32 +6576,Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,23 +9332,Elevated cholesterol and is on medication to lower it.,9 +2532," Colonoscopy, conscious sedation, and snare polypectomy.",14 +7270,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +10487,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7984,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +6989,Small office note on premature retina and vitreous.,26 +8093,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4102,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 +4320,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 +10497,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +5685,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +8236,Patient scheduled for laparoscopic gastric bypass.,2 +12624,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3924, Esophagogastroduodenoscopy and colonoscopy with polypectomy,38 +8377,Patient presents for care of suspected rheumatoid arthritis.,34 +6413,Intensity-modulated radiation therapy simulation note. The client will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.,16 +6912,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,29 +3290, Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. ,14 +4562,Routine colorectal cancer screening. He occasionally gets some loose stools.,16 +9317,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +3188, A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.,27 +4017,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +1374," Congestion, tactile temperature.",29 +11637,Is it BNP or BMP?,19 +6326,Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement.,12 +4282,Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 +10812,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +10885,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +7950,"Specimen labeled ""sesamoid bone left foot"".",19 +1335," This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. ",5 +2521, Symptomatic thyroid goiter. Total thyroidectomy.,10 +9467,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +1134," Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.",3 +548," Patient with chest pains, CAD, and cardiomyopathy.",33 +4293,"Followup diabetes mellitus, type 1.",35 +12117,Patient presents for care of suspected rheumatoid arthritis.,34 +5699,A 5-month-old boy brought by his parents because of 2 days of cough.,29 +2718, Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.,38 +8018,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid therapy to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +2045," Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.",24 +4184,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 +1640," MRI of the Cervical, Thoracic, and Lumbar Spine",27 +7604,Autopsy - Homicide - Blunt force cranial trauma,1 +2375, Patient presents complaining of abdominal pain and discomfort for 3 weeks.,5 +5680,"Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",10 +100, Tonsillectomy. Chronic tonsillitis.,38 +1510," Cystoscopy, cryosurgical ablation of the prostate.",38 +6858,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The client is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",29 +7466,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +10303,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +5705,Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,16 +12336,A sample note on Rheumatoid Arthritis,34 +9824,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1470," Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.",5 +7794,Chiropractic IME with answers to questions from Insurance Company.,4 +2380, Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. ,10 +1456, Foul-smelling urine and stomach pain after meals.,5 +1986, Patient developed iron deficiency anemia and had blood in his stool. ,35 +9390,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8263,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +11239,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +8423,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +7280,Autopsy - Asphyxia due to ligature strangulation.,1 +12161,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +292," Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.",38 +899, Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,32 +11107,Patient presents for therapy of suspected rheumatoid arthritis.,34 +5230,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +1772, Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 +2001, Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,21 +3907," Esophagogastroduodenoscopy, photography, and biopsy. Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.",14 +1947, MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,27 +7568,A 23-year-old white female presents with complaint of allergies.,0 +5596,"Followup diabetes mellitus, type 1.",13 +9702,A sample note on Rheumatoid Arthritis,34 +6603,Tonsillectomy. Chronic tonsillitis.,11 +55," This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.",39 +6138,"A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.",32 +5302,"Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",24 +3906," Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat. ",27 +12234,Mother states he has been wheezing and coughing.,0 +8709,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +12567,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +1620, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,38 +6012,MRI report Cervical Spine (Chiropractic Specific),4 +4501,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +5164,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +2817," T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 +8797,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +11502,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3328," Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",10 +12200,Dietary consultation for gestational diabetes.,9 +8892,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +2651, Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,32 +5593,Psychiatric History and Physical - Patient with schizoaffective disorder.,32 +3790, 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.,15 +8335,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +12288,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1581," Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",27 +9473,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9493,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +10750,Mother states he has been wheezing and coughing.,0 +12337,A sample note on Rheumatoid Arthritis,34 +4191,"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +4794,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +3760, Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.,22 +1056, Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,38 +7484,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +250," Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.",15 +3939," Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ",24 +7536,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10274,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +8134,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +9791,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2799, Inguinal orchiopexy procedure.,39 +7296,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8539,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11152,A sample note on Rheumatoid Arthritis,34 +11328,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +7236,"Specimen labeled ""sesamoid bone left foot"".",19 +3784," A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",11 +597," Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.",3 +10845,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +4991,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +10252,"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.",6 +12061,Autopsy of a white female who died of acute combined drug intoxication.,1 +812," MRI of the Cervical, Thoracic, and Lumbar Spine",33 +12178,A 23-year-old white female presents with complaint of allergies.,0 +7636,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1363, Colonoscopy to evaluate prior history of neoplastic polyps.,38 +3479," Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",14 +3097," Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",31 +10120,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +5922,Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 +11814,Patient presents for care of suspected rheumatoid arthritis.,34 +11342,"Specimen labeled ""sesamoid bone left foot"".",19 +10773,A sample note on Rheumatoid Arthritis,34 +11666,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +4001,"Bilateral Mammogram, (abnormal) additional views requested",33 +3956, Tracheotomy for patient with respiratory failure.,38 +3469, Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 +9667,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5714,Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 +10300,Completion thyroidectomy with limited right paratracheal node dissection.,13 +737, Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,5 +7267,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9295,Autopsy - Asphyxia due to ligature strangulation.,1 +3770, Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,3 +5012,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",29 +5141,"Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.",39 +9230,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +1843, Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +4266,The case comes in today because of feeling lightheaded and difficulty keeping his balance.,22 +86," Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.",27 +7586,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8350,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +4261,"The case is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.",32 +11847,A sample note on Rheumatoid Arthritis,34 +10817,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +851," Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",38 +807," Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",27 +2368," A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.",5 +6018,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant.,26 +947, Arterial imaging of bilateral lower extremities. ,33 +1791, Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.,38 +4658,A 65-year-old man with chronic prostatitis returns for recheck.,39 +12089,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2983," Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10689,Is it BNP or BMP?,19 +7500,Autopsy - Asphyxia due to ligature strangulation.,1 +7307,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7273,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10366,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +7084,Patient being referred for evaluation of glaucoma.,20 +2492, Well child - Left lacrimal duct stenosis,29 +5172,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 +3235, MRI right knee without gadolinium,33 +12519,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8514,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +9115,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +3107, Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +382," Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.",28 +3579, Blepharoplasty procedure,26 +2457," Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency",5 +3213," Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",14 +456," Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",5 +4601,"Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",23 +354," Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.",38 +1735," A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",5 +10778,A sample note on Rheumatoid Arthritis,34 +304," Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.",38 +8446,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10649,A 23-year-old white female presents with complaint of allergies.,0 +8305,Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +3735, Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex.,38 +11217,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7850,Evaluation for bariatric surgery.,2 +11541,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +8704,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +6915,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",29 +11278,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9048,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +10856,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +782," Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",38 +12514,Patient presents for care of suspected rheumatoid arthritis.,34 +6777,Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +9856,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2536, Chest tube talc pleurodesis of the right chest.,3 +9279,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +8989,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10988,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12546,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11397,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +8256,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +5911,The client underwent an overnight polysomnogram.,36 +7434,Mother states he has been wheezing and coughing.,0 +634," Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.",38 +8000,Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +5362,"Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",24 +3308," Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",38 +2598, Consultation for wrist pain.,4 +1821, Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.,3 +10507,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7914,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +11927,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.",30 +6225,Consult for laparoscopic gastric bypass.,2 +8736,Evaluation for bariatric surgery.,2 +10577,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7973,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +3258, Headache. Right frontal lobe glioma.,22 +711, Ligament reconstruction and tendon interposition arthroplasty of right wrist.,27 +8049,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +4043,Common description of colonoscopy,14 +10643,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +12097,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +9760,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1250," History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",30 +3362," This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.",5 +12106,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +7471,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11330,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +1188," A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 +9052,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +8323,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +2944," Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.",24 +5734,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +2206, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,38 +8228,Qualified clinical evaluation report of a patient with back pain.,18 +6640,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +3955," Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.",27 +11346,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +6428,"The client is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.",29 +4416,A 2-month-old female with 1-week history of congestion and fever x2 days.,29 +4528,"Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 +8042,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and discomfort to the left lower mandible area today.,7 +5071,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +5176,A 60-year-old female presents today for care of painful calluses and benign lesions.,31 +10894,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1869," Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",35 +8635,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11393,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +2377," Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.",3 +4241,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",15 +7384,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +5289,"Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.",28 +6928,"Sample normal ear, nose, mouth, and throat exam.",25 +1433," Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",31 +9050,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +3243, Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.,38 +3351, A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,5 +2959, The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.,15 +3981, Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,3 +4448,Bilateral renal ultrasound.,21 +7365,Occupational medicine consult with questions-answers and records review.,18 +1605," A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +8629,Chiropractic IME with answers to questions from Insurance Company.,4 +11277,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6699,"The patient is an 11-month-old with a identification of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",29 +1194," The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. ",5 +12014,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +3567, The patient was referred for evaluation of cataracts bilaterally,20 +12605,A sample note on Rheumatoid Arthritis,34 +2769," Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.",3 +1414, 3-Dimensional Simulation. This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.,33 +7700,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9684,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3816," Questionable foreign body, right nose. Belly and back pain. Mild constipation.",29 +9382,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2194," 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.",6 +12500,Autopsy - Asphyxia due to ligature strangulation.,1 +12172,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9027,MRI report Cervical Spine (Chiropractic Specific),4 +4312,"Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 +4467,Chiropractic IME with answers to questions from Insurance Company.,20 +7573,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8783,Dietary consultation for gestational diabetes.,9 +441," CT abdomen without contrast and pelvis without contrast, reconstruction.",21 +8659,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +4779,"Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",39 +4035,"Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.",24 +10519,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +2411," Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.",27 +9432,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +3033, Postpartum tubal ligation and removal of upper abdominal skin wall mass.,24 +8017,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +6091,Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +9009,A sample note on Rheumatoid Arthritis,34 +8009,A sample note on Rheumatoid Arthritis,34 +5324,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +8875,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10774,A sample note on Rheumatoid Arthritis,34 +8563,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +6599,Discharge summary of a case with mood swings and oppositional and defiant behavior.,32 +11832,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2243," Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",5 +3505, Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,33 +161, Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.,15 +4308,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 +881, Standard Laparoscopic Cholecystectomy Operative Note.,14 +5500,"Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 +5202,Normal vasectomy,39 +7333,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +484, Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,3 +5551,"Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",31 +7289,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7526,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2698," Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +6784,MRI right ankle.,31 +2503, Bronchoscopy for hypoxia and increasing pulmonary secretions,38 +12435,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2062," Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.",35 +2260, Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.,5 +8748,Occupational medicine consult with questions-answers.,18 +40," Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.",3 +119, Endoscopic third ventriculostomy.,38 +4492,Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,23 +8938,Chiropractic IME with answers to questions from Insurance Company.,18 +2878, Stage I and II neuromodulator.,38 +296, Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. ,38 +12000,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6467,"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.",26 +10669,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6848,Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe.,28 +5905,"Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",10 +5612,"Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",31 +817," 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.",24 +8205,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +8706,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +4453,"Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",24 +8063,Significant ache in left lower jaw.,7 +4208,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,15 +2036," Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.",38 +8128,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +3114," The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.",5 +1714, Mother states he has been wheezing and coughing.,0 +11007,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6755,The case is being referred for evaluation of diabetic retinopathy.,26 +6927,"Lower quadrant ache with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 +10388,"The case is a 26-year-old female, referred to Physical Therapy for low back pain. The case has a history of traumatic injury to low back.",30 +5999,Injection of bilateral carpal tunnels,28 +2578, Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.,15 +4226,Patient with episode of lightheadedness and suddenly experienced vertigo.,22 +1879, Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,27 +6207,Right pleural effusion and suspected malignant mesothelioma.,16 +11057,A sample note on Rheumatoid Arthritis,34 +1695, Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. ,14 +12469,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +5012,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",29 +4948,Follow up update on case with left carotid angioplasty and stent placement.,20 +3188, A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.,27 +4268,The client comes in today because of feeling lightheaded and difficulty keeping his balance.,22 +7423,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +5635,"Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 +6204,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +11795,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5492,"Patient suffers from neck and lower back discomfort radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +9524,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1913," Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",5 +6501,"Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",21 +6563,Patient in ER complaining of shortness of breath (COPD),12 +4882,"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.",39 +10202,A sample note on Rheumatoid Arthritis,34 +948," Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",25 +5824,Underwent tonsillectomy and adenoidectomy two weeks ago.,25 +5280,"Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.",21 +942, Inguinal hernia hydrocele repair.,38 +2624, Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.,24 +6569,Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 +12004,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +9906,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1269," Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.",24 +5011,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",29 +7222,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8044,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +3189, Normal cataract surgery. ,38 +436, Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,5 +5429,The case was referred due to concerns regarding behavioral acting out as well as encopresis.,32 +135," Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",38 +2140," Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",15 +3531," The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",5 +2383, Nephrology office visit for followup of CKD.,21 +7690,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +1652, Urgent cardiac catheterization with coronary angiogram.,3 +8568,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +3417, 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.,29 +8881,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +4796,"CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",22 +7578,Is it BNP or BMP?,19 +3435," Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +11854,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +4086,"Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",16 +3741," CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",38 +6757,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +4180,Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,39 +3623," Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.",5 +10832,Autopsy of a white female who died of acute combined drug intoxication.,1 +950, Colonoscopy in a patient with prior history of anemia and abdominal bloating.,14 +11652,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2183, Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,3 +6635,The case is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,29 +1959, Sleep study - patient with symptoms of obstructive sleep apnea with snoring.,22 +1738," Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",12 +525, CT chest with contrast.,33 +11969,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4392,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The case is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",16 +5697,Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy.,16 +5866,"Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 +927, A 23-year-old white female presents with complaint of allergies.,35 +5292,"Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 +9624,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9068,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +9093,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +5862,Left hip fracture. The case is a 53-year-old female with probable pathological fracture of the left proximal femur.,12 +1708, A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.,35 +6601,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The client fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +6318,Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,26 +1644," Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.",38 +12393,Chiropractic IME with answers to questions from Insurance Company.,4 +579," Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",10 +1468, Return to work & Fit for duty evaluation.,15 +5271,"Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",23 +6365,Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,11 +9149,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +10902,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +9376,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7112,Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,26 +12037,MRI report Cervical Spine (Chiropractic Specific),4 +10426,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +4281,Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 +1763," Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 +2804, Vitrectomy under local anesthesia.,38 +4397,Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,35 +3050," Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.",38 +11756,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10127,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +5274,Pediatric Gastroenterology - Rectal Bleeding Consult.,29 +338, Evaluation for chronic pain program,27 +11172,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +9691,A sample note on Rheumatoid Arthritis,34 +10494,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +291, Chiropractic IME with answers to questions from Insurance Company.,20 +12627,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3782, Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3881," A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",32 +2043," Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.",14 +2338, Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,38 +3355, Pediatric Gastroenterology - Rectal Bleeding Consult.,14 +12386,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10854,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +8732,Evaluation for bariatric surgery.,2 +5595,"Followup diabetes mellitus, type 1.",13 +11699,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7408,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5220,Adenotonsillectomy. Adenotonsillitis with hypertrophy. The case is a very nice case with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +9071,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +11504,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +5663,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 +6030,Urgent cardiac catheterization with coronary angiogram.,12 +4766,Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,39 +4434,Upper endoscopy with foreign body removal (Penny in proximal esophagus).,14 +486," Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. ",12 +5692,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 +11030,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +3357, A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.,27 +10082,Is it BNP or BMP?,19 +8548,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +5583,Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.,10 +3266," Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.",27 +6801,"9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.",20 +6147,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +9226,Cause of death - Anoxic Encephalopathy,1 +4442,4-day-old with hyperbilirubinemia and heart murmur.,12 +301," Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +8864,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11220,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +1542," Circumcision. A dorsal slit was made, and the prepuce was dissected away from the glans penis.",38 +260," Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.",38 +4471,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The client was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 +10383,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +816, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,22 +9061,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +751, Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.,33 +37," Pressure decubitus, right hip",15 +10738,"Specimen labeled ""sesamoid bone left foot"".",19 +10319,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +6701,"The case is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",29 +10421,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +507, Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 +8245,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +5693,2-month-old female - increased work of breathing.,12 +6702,Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 +2558," MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.",33 +4324,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +700, Left third digit numbness and wrist pain.,33 +3540," Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.",27 +785, Vaginal discharge with a foul odor.,24 +8745,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11990,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +12657,Patient presents for therapy of suspected rheumatoid arthritis.,34 +2483," Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",15 +1442," Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.",27 +2957, Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,5 +7803,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12372,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +12505,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +10073,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +3367, This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. ,35 +10794,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +320," Pregnant female with nausea, vomiting, and diarrhea. OB ultrasound less than 14 weeks, transvaginal.",33 +9090,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +5618,The client is being discharged for continued hemodialysis and rehab.,21 +6788,Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib discomfort related to a herniated nucleus pulposus at T8-T9.,23 +6227,"Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.",28 +11336,"Followup diabetes mellitus, type 1.",13 +12540,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9726,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +125, Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,15 +5415,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 +10390,"The case is a 26-year-old female, referred to Physical Therapy for low back pain. The case has a history of traumatic injury to low back.",30 +5227,"Head injury, anxiety, and hypertensive emergency.",29 +10636,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +9020,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +9476,Autopsy - Homicide - Blunt force cranial trauma,1 +10697,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7969,Chiropractic IME with answers to questions from Insurance Company.,18 +10329,Evaluation for chronic ache program,4 +12619,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +9383,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6216,"The client is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 +4709,Spermatocelectomy and orchidopexy,39 +11443,Consult for laparoscopic gastric bypass.,2 +3561," Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.",38 +2256, Consult for laparoscopic gastric bypass.,2 +1424," Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",26 +5614,"Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",31 +1064," Essential thrombocytosis. He underwent a bone marrow biopsy, which showed essential thrombocytosis. His CBC has been very stable. ",35 +6892,Osteoarthritis of the right knee. Right knee joint steroid injection.,28 +7264,Cause of death - Anoxic Encephalopathy,1 +11373,A sample note on Rheumatoid Arthritis,34 +10447,Qualified medical evaluation report of a case with back pain.,4 +8695,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +6002,The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal ache which has been persistent.,12 +8855,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +4693,"Cerebrovascular accident (CVA). The case presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.",12 +3100," Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",21 +7305,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4162,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +2224, Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.,38 +2914, Patient with complaint of symptomatic cholelithiasis.,14 +9104,Preop evaluation regarding gastric bypass surgery.,2 +1293," Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.",35 +7601,Autopsy - Homicide - Blunt force cranial trauma,1 +3446, Chronic headaches and pulsatile tinnitus.,5 +11094,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +377, Patient with a three-day history of emesis and a four-day history of diarrhea,15 +7593,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11225,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +9635,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6791,"Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 +8623,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +8755,Occupational medicine consult with questions-answers.,18 +11641,Is it BNP or BMP?,19 +3768," Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",35 +9205,Evaluation for chronic ache program,4 +6414,Consult for laparoscopic gastric bypass.,2 +7925,Patient referred for narrow angles and possible associated glaucoma.,20 +11673,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +3745, Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.,3 +5957,"A 49-year-old female with ankle discomfort times one month, without a specific injury.",31 +1013," L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.",38 +10688,Is it BNP or BMP?,19 +5379,"Discharge Summary of a client with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.",10 +11052,Autopsy - Homicide - Blunt force cranial trauma,1 +1481, Noncontrast CT head due to seizure disorder.,33 +589, MRI left shoulder.,27 +16," Complex regional pain syndrome, right upper extremity. Stellate ganglion block.",28 +8834,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +11701,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7917,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +7614,A sample note on Rheumatoid Arthritis,34 +4867,"Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 +11001,A 23-year-old white female presents with complaint of allergies.,0 +2749," 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.",16 +10293,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +2498, Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,26 +12449,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +2042, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today.,7 +7185,Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 +10400,Chronic snoring in children,36 +12271,Autopsy of a white female who died of acute combined drug intoxication.,1 +4137,"The client is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",12 +3622," CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",33 +1157, Arthroscopic procedure of the knee.,38 +5808,Bilateral sacroiliac joint injections,28 +7300,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6967,"A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.",31 +7380,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8508,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +5830,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +9482,Autopsy - Homicide - Blunt force cranial trauma,1 +83, Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,39 +2052," A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",35 +10280,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4741,"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient therapy and increased mood lability.",32 +12478,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +1612, An example/template for a routine normal female physical exam.,15 +11877,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5968,Laparoscopic right partial nephrectomy due to right renal mass.,21 +699, Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 +12462,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +1504, The patient states that he feels sick and weak.,15 +931, Left elbow manipulation and hardware removal of left elbow.,38 +1889, The patient seeks evaluation for a second opinion concerning cataract extraction. ,35 +4728,"A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",35 +8075,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +10156,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +6159,Significant discomfort in left lower jaw.,7 +757, Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,3 +534, Consult for prostate cancer,5 +364, A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.,22 +3003, An example of a physical exam,15 +7351,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3847," Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.",3 +764, A two week well-child check.,29 +8168,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +12339,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4024,Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,23 +1460," Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. ",38 +11077,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5040,Psychosocial Evaluation of case before kidney transplant.,32 +3359," Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",16 +10544,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +8253,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +11644,Dietary consultation for diabetes during pregnancy.,9 +275," Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.",38 +11144,A sample note on Rheumatoid Arthritis,34 +5719,The client seeks evaluation for a second opinion concerning cataract extraction.,26 +1324," Patient with several medical problems - numbness, tingling, and a pain in the toes.",5 +1434," Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization.",38 +2456, A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,27 +1193," Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",38 +1746," Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",5 +2365, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,10 +12626,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10392,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +9114,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7339,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2563, Whole body PET scanning.,33 +7363,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2844, Tonsillectomy. Chronic tonsillitis.,11 +7058,Quick note on tachypnea.,25 +3337," Multiple contusions and abdominal pain, status post motor vehicle collision. ",15 +3289, Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,15 +7033,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +6378,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +3349, The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,5 +1005," Marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. she had a mammogram and ultrasound, which confirmed the right breast mass.",5 +4888,Transforaminal epidural steroid block with fluoroscopy.,28 +1684," Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",14 +12561,A 23-year-old white female presents with complaint of allergies.,0 +6158,Significant discomfort in left lower jaw.,7 +6243,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +11992,Dietary consultation for diabetes during pregnancy.,9 +5147,Evaluation for bariatric surgery.,2 +9912,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +1291," Laparotomy and myomectomy. Enlarged fibroid uterus and blood loss anemia. On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.",38 +4480,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,33 +6646,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +7566,A 23-year-old white female presents with complaint of allergies.,0 +12280,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +10224,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +815," Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.",38 +4671,"The case noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",39 +10595,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10043,"The skin biopsy was performed on the right ankle and right thigh. The case was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +4927,"Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",31 +1693," Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 +1927, Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.,39 +9766,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10187,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11987,Occupational medicine consult with questions-answers and records review.,18 +7909,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +4345,"Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.",14 +11557,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2950," Left buttock abscess, status post incision and drainage. Recommended some local wound care",5 +10469,Work restrictions and disability evaluation,4 +6537,"Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye",26 +10848,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +6854,"Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",11 +10104,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +11448,Encephalopathy related to normal-pressure hydrocephalus.,30 +266," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",27 +8380,"Records review. The patient developed shooting discomfort about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +10991,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9970,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +11059,A sample note on Rheumatoid Arthritis,34 +4973,Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 +8677,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +10698,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7043,Nephrology office visit for followup of microscopic hematuria.,25 +761," A white female who presents for complete physical, Pap and breast exam.",24 +1739," A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +3185," The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.",30 +10203,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +4106,"Right shoulder impingement syndrome, right suprascapular neuropathy.",22 +5028,"This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy.",35 +6263,Patient presents to the emergency department (ED) with rectal bleeding and ache on defecation.,12 +1026," This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +2071, Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +3586, Left shoulder pain. Evaluate for rotator cuff tear.,33 +3127, Blepharoplasty with direct brow repair.,26 +8351,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4577,Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.,29 +3515, MRI Brain & T-spine - Demyelinating disease.,27 +5348,Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.,11 +4962,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +10612,Chiropractic IME with answers to questions from Insurance Company.,4 +10174,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +11627,Dietary consultation for gestational diabetes.,9 +5594,"Followup diabetes mellitus, type 1.",13 +6724,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +11460,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +5771,"Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +6417,"Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",23 +6934,CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 +10407,Dietary consultation for carbohydrate counting for type I diabetes.,9 +11912,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +11978,Is it BNP or BMP?,19 +4541,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",35 +7249,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +868, Bilateral open Achilles lengthening with placement of short leg walking cast.,27 +11046,Autopsy - Homicide - Blunt force cranial trauma,1 +12284,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11778,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8970,Mother states he has been wheezing and coughing.,0 +2388," This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",5 +12347,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11961,A 23-year-old white female presents with complaint of allergies.,0 +11781,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4598,"Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.",22 +4334,Esophagogastroduodenoscopy performed in the emergency department.,14 +6874,"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.",23 +2778, OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.,38 +9569,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3804, Caudal epidural steroid injection without fluoroscopy.,28 +3178, Arthroscopic procedure of the knee.,27 +497, This patient was seen in clinic for a school physical.,5 +6673,Sample/template for a normal female multisystem exam,25 +10313,Encephalopathy related to normal-pressure hydrocephalus.,30 +9470,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +731, Dietary consultation for diabetes during pregnancy.,5 +2073, Standard celiac plexus block procedure note.,28 +12414,Is it BNP or BMP?,19 +10143,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +6044,Letter to the case to let him know about his abnormal cholesterol test results.,20 +2547, Patient with complaint of symptomatic cholelithiasis.,10 +4495,Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 +5243,Psychosocial Evaluation of case before kidney transplant.,21 +1257, Pain management sample progress note.,35 +9496,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +2812," Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",5 +4438,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",35 +8612,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +1809," Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction",5 +4731,A sample note on Cataract,26 +6983,Patient with right ankle pain.,31 +7076,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +7062,"Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",31 +5849,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +11758,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +9741,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10220,Letter to the case to let him know about his abnormal cholesterol test results.,20 +10194,The case underwent an overnight polysomnogram.,36 +1406," The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ",5 +10361,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +7533,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11142,A sample note on Rheumatoid Arthritis,34 +12087,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +11813,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6895,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +10605,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +8511,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +983, Pain. Three views of the right ankle. Three views of the right ankle are obtained.,27 +5825,"Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",12 +8277,Initial evaulation - neck and back pain.,4 +4061,Foul-smelling urine and stomach discomfort after meals.,14 +122, Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 +3558, Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma. ,38 +5722,Transnasal transsphenoidal approach in resection of pituitary tumor. The client is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 +8979,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +513, The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,37 +2962, Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,16 +6089,Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +12235,Mother states he has been wheezing and coughing.,0 +5110,"School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 +4605,Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.,23 +9727,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6042,"Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",23 +2972, Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 +12114,Elevated cholesterol and is on medication to lower it.,9 +8851,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +10205,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +2224, Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.,38 +12461,Autopsy of a white female who died of acute combined drug intoxication.,1 +8201,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +3573," Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.",27 +6290,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,16 +6935,CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 +5185,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",21 +5127,"Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",10 +5471,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +8991,Autopsy - Homicide - Blunt force cranial trauma,1 +9440,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +2448, Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,38 +10472,Work restrictions and disability evaluation,4 +8546,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +6309,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear ache resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",12 +11766,Cause of death - Anoxic Encephalopathy,1 +5031,"Plantar fascitis, left foot. Partial plantar fasciotomy.",31 +11365,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2925," Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",15 +3365," Sample normal ear, nose, mouth, and throat exam.",25 +9002,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +12032,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +11840,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10516,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +6496,"CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",21 +2678," CT abdomen and pelvis without contrast, stone protocol, reconstruction.",21 +2458," Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 +5843,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +4329,"Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.",22 +9002,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +9995,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +11352,Consultation for left foot pain.,4 +4234,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5250,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",12 +8971,Mother states he has been wheezing and coughing.,0 +12308,Patient presents for care of suspected rheumatoid arthritis.,34 +11487,"Synovitis - anterior cruciate ligament tear of the left knee. The client is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The client fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +6509,"Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.",23 +158," The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",32 +4608,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +2924, Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. ,38 +11391,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +7976,Mother states he has been wheezing and coughing.,0 +2179," The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.",22 +8957,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +6844,Acne with folliculitis.,8 +9411,A 23-year-old white female presents with complaint of allergies.,0 +9599,Patient presents for care of suspected rheumatoid arthritis.,34 +4867,"Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 +7679,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +1794, Left heart cardiac catheterization.,3 +4864,"Nuclear sclerotic cataract, right eye. Kelman phacoemulsification with posterior chamber intraocular lens, right eye.",26 +11351,Chiropractic IME with answers to questions from Insurance Company.,18 +9618,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6030,Urgent cardiac catheterization with coronary angiogram.,12 +2164, Circumcision and release of ventral chordee.,39 +5103,Patient is here to discuss possible open lung biopsy.,35 +11442,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7158,Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.,25 +5237,Single frontal view of the chest. Respiratory distress. The client has a history of malrotation.,29 +3728, Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,38 +1825," Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants. Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.",38 +87, Initial evaulation - neck and back pain.,5 +8520,Chiropractic IME with answers to questions from Insurance Company.,20 +6185,"Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 +11983,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +11552,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7311,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4878,"Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",10 +236," He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",15 +6694,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5057,"Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 +6692,"A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This client may have had reactive arthritis.",29 +11591,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +3968, Well-child check and school physical.,29 +5257,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.,23 +3439, Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. ,35 +3692, Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.,21 +3584," Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.",23 +4159,"A complex closure and debridement of wound. The case is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",23 +6821,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +5125,Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,23 +6451,Encephalopathy related to normal-pressure hydrocephalus.,30 +813," Patient had some cold symptoms, was treated as bronchitis with antibiotics.",3 +2040," The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.",5 +544," Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. +",38 +10930,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3143," Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 +2977," Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location. ",14 +1519, Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.,27 +7190,Patient presents for care of suspected rheumatoid arthritis.,34 +3554," Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.",38 +290, An example/template for a routine normal female physical exam.,5 +2861," Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, +and congestive heart failure.",10 +1530, PICC line insertion,38 +4523,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11526,Elevated cholesterol and is on medication to lower it.,9 +10393,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +9857,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +10592,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +1852, Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,3 +1242, Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. ,3 +12005,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +10306,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +473, The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.,38 +7693,Procedure note on Keller Bunionectomy,31 +12562,A 23-year-old white female presents with complaint of allergies.,0 +12362,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3629, Patient with confusion and hallucinations.,15 +4761,An example/template for a routine normal male physical exam.,25 +3227, Total abdominal hysterectomy (TAH) with a uterosacral vault suspension. Enlarged fibroid uterus and abnormal uterine bleeding. ,38 +2201," Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.",38 +9304,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +11682,"Specimen labeled ""sesamoid bone left foot"".",19 +10363,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +2883," Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.",38 +10801,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +10315,Encephalopathy related to normal-pressure hydrocephalus.,30 +249, Patient with dysphagia.,38 +6705,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +4870,"Right inguinal hernia. Right inguinal hernia repair. The case is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 +8373,Evaluation and recommendations regarding facial rhytids.,8 +9146,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4284,"Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.",35 +2228, MRI Head W&WO Contrast.,22 +3288, MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.,33 +3437, MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),22 +8580,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10235,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +9459,Mother states he has been wheezing and coughing.,0 +937, Evaluation for bariatric surgery.,2 +2055, Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,10 +11138,A sample note on Rheumatoid Arthritis,34 +3592, Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,14 +5944,"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +10246,Preop evaluation regarding gastric bypass surgery.,2 +2635, Tonsillectomy. Tonsillitis. McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. ,38 +5062,"This is a 53-year-old man, who presented to emergency room with multiple complaints including discomfort from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.",12 +1385," Orthopedic progress note for follow up of osteoarthritis, knees.",27 +2156," The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ",10 +2938, Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,38 +5767,Evaluation for right L4 selective nerve root block.,28 +3272," Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.",3 +3957, Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,27 +9893,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +7658,Patient presents for therapy of suspected rheumatoid arthritis.,34 +8639,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5333,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +3806, MRI T-spine and CXR - Aortic Dissection.,22 +7647,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8705,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +12491,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10433,Autopsy - Asphyxia due to ligature strangulation.,1 +817," 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.",24 +10601,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6900,"The client is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.",16 +4201,"Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 +11073,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1578," Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.",3 +6323,Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 +988," Phacoemulsification of cataract, extraocular lens implant in left eye.",38 +12534,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7747,An example/template for a routine normal male physical exam.,25 +10238,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +368," Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",38 +6677,Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 +8110,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +1370, CT REPORT - Soft Tissue Neck,27 +9538,Cause of death - Anoxic Encephalopathy,1 +1395," Chest pain, Chest wall tenderness occurred with exercise.",3 +4252,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +7930,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +12410,Dietary consultation for gestational diabetes.,9 +1955," This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.",22 +8493,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +5572,"Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 +9442,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10505,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3435," Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +291, Chiropractic IME with answers to questions from Insurance Company.,20 +8398,Work restrictions and disability evaluation,4 +10849,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +5052,"The client presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",24 +6618,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",16 +11632,Dietary consultation for gestational diabetes.,9 +1626, Sample progress note - Gen Med.,35 +11329,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating discomfort in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +7004,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +766, Patient with fever of unknown origin.,10 +6910,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,29 +12541,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3454," CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).",22 +7091,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +8350,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +3109, Short-term memory loss (probable situational) and anxiety stress issues.,15 +6287,Occupational medicine consult with questions-answers and records review.,18 +7048,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient therapy with nitrofurantoin.,12 +9508,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +10330,Evaluation for chronic ache program,4 +2223," Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",15 +12227,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +1148," Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",23 +8105,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +4033,"Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.",23 +9803,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5607,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +2611, Common CT Chest template,3 +2998," Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.",38 +8397,Work restrictions and disability evaluation,4 +8437,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +10744,Mother states he has been wheezing and coughing.,0 +12027,Autopsy - Homicide - Blunt force cranial trauma,1 +6745,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 +12207,Is it BNP or BMP?,19 +3799, The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails. ,31 +2661, Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.,38 +8297,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +10381,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +3523, Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy.,16 +9781,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2748, A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,22 +8187,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +501, Spermatocelectomy and orchidopexy,39 +10958,Patient presents for care of suspected rheumatoid arthritis.,34 +7796,Chiropractic IME with answers to questions from Insurance Company.,4 +9720,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +10753,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +6189,Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 +12220,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +6865,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +5587,Pediatric Gastroenterology - History of gagging.,29 +11021,Is it BNP or BMP?,19 +979, Repair of upper lid canalicular laceration - Sample/Template.,38 +9605,Patient presents for care of suspected rheumatoid arthritis.,34 +2895," Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.",3 +4681,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,22 +8616,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +2616," Left pleural effusion, parapneumonic, loculated. Left chest tube placement.",3 +5433,"Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",28 +4871,"Right inguinal hernia. Right inguinal hernia repair. The client is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 +3604, An example/template for a routine normal male ROS.,15 +3099, HCT for memory loss and for calcification of basal ganglia (globus pallidi).,22 +3969, Dobutrex stress test for abnormal EKG,3 +630, Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.,38 +11966,Evaluation for bariatric surgery.,2 +7245,Autopsy - Homicide - Blunt force cranial trauma,1 +532, The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,5 +4166,The client is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 +5515,An example/template for a routine normal male ROS.,25 +11510,Autopsy - Asphyxia due to ligature strangulation.,1 +10036,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +7079,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +7433,"Specimen labeled ""sesamoid bone left foot"".",19 +11099,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7170,Elevated cholesterol and is on medication to lower it.,9 +5208,Occupational medicine consult with questions-answers.,18 +7300,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7256,Autopsy of a white female who died of acute combined drug intoxication.,1 +1065," Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",24 +7274,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8007,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +6746,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 +3, MRI Brain: Thrombus in torcula of venous sinuses.,33 +2403, Insertion of transvenous pacemaker for tachybrady syndrome,38 +4251,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +3167, Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. ,24 +1833," Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.",38 +1219, Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 +5146,Evaluation for bariatric surgery.,2 +8802,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +9376,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3941," Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle. ",38 +89, Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.,38 +12029,A sample note on Rheumatoid Arthritis,34 +9744,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7580,Is it BNP or BMP?,19 +5369,Fractional dilatation and curettage,24 +11787,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +7313,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3577," Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.",15 +11423,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +2245, This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,22 +11158,A sample note on Rheumatoid Arthritis,34 +10544,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +5204,Normal vasectomy,39 +6552,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +5207,"Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +6686,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 +9526,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6047,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +855," First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +44," The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",24 +0," Bilateral Mammogram, (abnormal) additional views requested",33 +1935, Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 +2370," Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.",38 +8868,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +3839, Endovascular Brachytherapy (EBT),33 +7028,Diagnosis of benign rolandic epilepsy.,20 +10749,Mother states he has been wheezing and coughing.,0 +696, Patient with history of adenomas and irregular bowel habits.,14 +5729,"Right hand laceration x3, repaired.",25 +4294,"Followup diabetes mellitus, type 1.",35 +2104," Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.",5 +8448,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6457,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +4952,Knee injection,28 +11358,Mother states he has been wheezing and coughing.,0 +512," Incompetent glottis. Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.",38 +1828, Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,3 +10402,Chronic snoring in children,36 +2461, Exploratory laparotomy and right salpingectomy.,24 +1722," Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.",38 +5695,2-month-old female - increased work of breathing.,12 +10032,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +12002,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +7615,A sample note on Rheumatoid Arthritis,34 +9928,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +459," Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.",38 +4446,Followup circumcision. The client had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 +5006,"He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",35 +5081,"Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and ache for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",39 +11181,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7750,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +7640,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11222,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +8960,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +4335,Esophagogastroduodenoscopy performed in the emergency department.,14 +1477, Evaluation for right L4 selective nerve root block.,27 +3370, Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.,10 +4856,"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 +6203,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +4147,"Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",11 +11859,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6007,Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +1661, Consultation for evaluation of thrombocytopenia.,16 +909, 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. ,14 +12640,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2289," Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.",27 +2776, Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,39 +4762,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",35 +4824,A white female presents for exam and Pap.,24 +9683,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +541," Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.",27 +8239,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +5216,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The case was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 +4844,Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,24 +10379,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +4698,"Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",24 +9040,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +6619,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",16 +11698,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9443,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +4716,"Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",35 +7211,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10546,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1452, Patient today with multiple issues. ,35 +5393,"Fever, otitis media, and possible sepsis.",29 +8553,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +499," Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",38 +4277,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 +9202,Consultation for wrist pain.,4 +6080,"Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",10 +2560," The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.",29 +9895,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +1349, Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.,38 +3123, Probable Coumadin hypersensitivity.,15 +772," Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.",15 +1182, Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,5 +1528, Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage. ,38 +4900,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +64, Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.,38 +10533,Occupational medicine consult with questions-answers and records review.,18 +4652,She was admitted following an overdose of citalopram and warfarin. The client has had increasing depression and has been under stress as a result of dissolution of her second marriage.,32 +2646, Normal child physical exam template.,29 +8664,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +2597, Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,38 +774," Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.",23 +862," Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",39 +5707,Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,16 +10803,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +5508,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +5999,Injection of bilateral carpal tunnels,28 +8209,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +4363,Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 +4938,Left retrosigmoid craniotomy and excision of acoustic neuroma.,23 +2521, Symptomatic thyroid goiter. Total thyroidectomy.,10 +7945,A simple note on Acne Vulgaris.,8 +1329, Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,38 +1705, CT Brain: Subarachnoid hemorrhage.,22 +8697,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +4095,"Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +9740,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5725,Adenoidectomy procedure,11 +7755,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +388," Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ",22 +7267,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12652,Patient presents for care of suspected rheumatoid arthritis.,34 +2082, Speech therapy discharge summary. The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits. ,37 +6503,"Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",21 +10502,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3625," Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",27 +9486,A sample note on Rheumatoid Arthritis,34 +3914," Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.",24 +9917,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1884," Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +4654,A 47-year-old female with a posttraumatic AV in the right femoral head.,10 +5982,Patient has prostate cancer with metastatic disease to his bladder. The case has had problems with hematuria in the past. The case was encouraged to drink extra water and was given discharge instructions on hematuria.,12 +868, Bilateral open Achilles lengthening with placement of short leg walking cast.,27 +6823,"Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.",21 +12355,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +11127,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +562, Patient with a diagnosis of stroke.,5 +4696,"Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",24 +2587," Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ",24 +1901," A 49-year-old female with ankle pain times one month, without a specific injury. ",31 +5371,Ultrasound OB - followup for fetal growth.,24 +48, Neurologic consultation and follow-up.,5 +7902,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +969," Left flank pain, ureteral stone.",39 +10201,A sample note on Rheumatoid Arthritis,34 +5224,"Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",24 +5975,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",26 +1415," Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.",3 +5919,Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,16 +5881,Bilateral temporal artery biopsy. Rule out temporal arteritis.,23 +5559,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +9219,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +6864,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +11040,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +667, A sample note on bilateral myringotomy tubes,11 +11629,Dietary consultation for gestational diabetes.,9 +8611,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +7130,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +8051,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +1919, Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,38 +7118,The client presents for evaluation at the request of his primary physician for treatment for dystrophic nails.,31 +685," Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.",38 +4606,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +10606,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +10935,Autopsy - Asphyxia due to ligature strangulation.,1 +2713, Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain,3 +6213,CT Abdomen & Pelvis W&WO Contrast,21 +7965,Blepharoplasty procedure,6 +2765, Consult and Spinal fluid evaluation in a 15-day-old,5 +93," Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. ",38 +3273, The patient was running and twisted her right ankle - right ankle sprain.,27 +9854,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +12085,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1444," Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",38 +4805,Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.,22 +2213, Excision of penile skin bridges about 2 cm in size.,38 +7516,Patient presents for care of suspected rheumatoid arthritis.,34 +5531,A female with unknown gestational age who presents to the ED after a suicide attempt.,12 +1141, Cardiology office visit sample note.,3 +10658,Work restrictions and disability evaluation,18 +2579, Sample progress note - Gen Med.,35 +11072,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1158, Follow up update on patient with left carotid angioplasty and stent placement.,3 +739," Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +6373,Well child - Left lacrimal duct stenosis,29 +2289," Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.",27 +3111, Questionable need for antibiotic therapy for possible lower extremity cellulitis.,15 +9822,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8935,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +7972,Consultation for left foot pain.,4 +9262,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2216, Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.,14 +12330,A sample note on Rheumatoid Arthritis,34 +5933,A sample note on Rheumatoid Arthritis,34 +11920,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +1560," Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",27 +11978,Is it BNP or BMP?,19 +12409,Dietary consultation for gestational diabetes.,9 +4192,"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +146, Decreased ability to perform daily living activities secondary to right knee surgery.,10 +4858,Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The client was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,21 +10777,A sample note on Rheumatoid Arthritis,34 +10161,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +7753,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +5442,Hand dermatitis.,8 +12269,Autopsy of a white female who died of acute combined drug intoxication.,1 +6951,"Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 +11816,Patient presents for care of suspected rheumatoid arthritis.,34 +1322," Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.",3 +1924, Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +2946," Left heart catheterization, left ventriculography, selective coronary angiography.",3 +3411," Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",16 +7218,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7407,A 23-year-old white female presents with complaint of allergies.,0 +6230,"Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 +7519,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6634,The client is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,29 +7930,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +9143,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +2645, Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,3 +6214,CT Abdomen & Pelvis W&WO Contrast,21 +5651,A white female with a history of fevers.,10 +3715, Full-mouth extraction of teeth and alveoloplasty in all four quadrants.,38 +11457,Evaluation for chronic ache program,4 +1885, Coil embolization of patent ductus arteriosus.,3 +12407,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +853," Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed.",27 +1835, MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,33 +3326, Sample post dilation patient instructions.,26 +1329, Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,38 +7418,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +1575," Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. ",14 +8650,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +2023, A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,10 +7061,"Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",31 +11432,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +7761,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +3980, Diagnostic cerebral angiogram and transcatheter infusion of papaverine,22 +11663,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +607," Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.",38 +808, Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. ,5 +10250,Significant discomfort in left lower jaw.,7 +4515,Psychiatric evaluation for major depression without psychotic features.,32 +5528,Bilateral tympanostomy with myringotomy tube placement. The client is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.,29 +2000, Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +3293, Osteoarthritis of the right knee. Right knee joint steroid injection.,28 +5397,"The case is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.",12 +5092,"Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",11 +3776," Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",38 +3688, Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 +586, Psychiatric History and Physical - Patient with schizoaffective disorder.,5 +9651,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10990,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8156,Evaluation for chronic discomfort program,4 +9011,A sample note on Rheumatoid Arthritis,34 +6698,"Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",11 +8080,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +3632, Bilateral reduction mammoplasty for bilateral macromastia,38 +27, Bilateral Myringotomy with placement of PE tubes,11 +11253,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +1264, Bilateral vasovasostomy surgery sample.,38 +9," Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +10529,Occupational medicine consult with questions-answers and records review.,18 +2002," Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.",38 +6771,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 +10369,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11935,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +6566,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +5106,The case was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,16 +1747, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,38 +5557,Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 +10443,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10840,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +6340,Completion thyroidectomy with limited right paratracheal node dissection.,13 +12403,A 23-year-old white female presents with complaint of allergies.,0 +12566,A 23-year-old white female presents with complaint of allergies.,0 +238," Emergent subxiphoid pericardial window, transesophageal echocardiogram.",3 +2006, Pain. Three views of the right ankle. Three views of the right ankle are obtained.,33 +1197," Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.",38 +12357,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +5913,"Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.",10 +8771,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +6826,"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 +5590,"Patient with a determination of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",21 +8882,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +2785, Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 +4531,Sample for Neuropsychological Evaluation,32 +7052,Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 +6453,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +5338,Psychiatric Consultation of case with dementia.,32 +3368, MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,27 +11937,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +2888, Patient in emergency room due to high potassium value.,15 +2426, Total colonoscopy and polypectomy,38 +4759,An example/template for a routine normal male physical exam.,25 +1910, Right pontine pyramidal tract infarct.,22 +7894,Hand dermatitis.,8 +5214,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The case was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 +7126,"Questionable foreign body, right nose. Belly and back pain. Mild constipation.",29 +10079,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +3824, Sample/template for a normal male multisystem exam.,15 +299, Esophagogastroduodenoscopy and colonoscopy with polypectomy,14 +12389,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +11747,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +11327,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +5938,Patient presents with complaint of lump in the upper outer quadrant of the right breast,16 +11683,"Specimen labeled ""sesamoid bone left foot"".",19 +9583,Autopsy - Asphyxia due to ligature strangulation.,1 +8368,"The client with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +10162,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +1061, Fifth disease with sinusitis,35 +9548,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +938, Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.,3 +5827,"Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",12 +7405,A 23-year-old white female presents with complaint of allergies.,0 +7560,A 23-year-old white female presents with complaint of allergies.,0 +11355,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +9502,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12207,Is it BNP or BMP?,19 +6562,Patient in ER complaining of shortness of breath (COPD),12 +454," Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.",23 +11872,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +9302,Autopsy - Asphyxia due to ligature strangulation.,1 +8116,Completion thyroidectomy with limited right paratracheal node dissection.,13 +11808,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8902,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +7705,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 +7047,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent identification of urinary tract infection on outpatient treatment with nitrofurantoin.,12 +5765,Evaluation for right L4 selective nerve root block.,28 +10376,Patient scheduled for laparoscopic gastric bypass.,2 +893, General Medicine SOAP note.,15 +12333,A sample note on Rheumatoid Arthritis,34 +6250,Autopsy of a white female who died of acute combined drug intoxication.,1 +8773,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +11801,Autopsy - Asphyxia due to ligature strangulation.,1 +2349, Dietary consultation for gestational diabetes.,35 +8707,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +8208,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +10106,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +2416," Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.",5 +8879,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating discomfort in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +3279," Normal physical exam template. Well developed, well nourished, in no acute distress.",25 +3451," Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan.",3 +5513,An example/template for a routine normal male ROS.,25 +11800,Autopsy - Asphyxia due to ligature strangulation.,1 +5638,Patient had a markedly abnormal stress test with severe chest ache after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,25 +10570,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +2879," Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.",24 +1512," Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.",14 +8687,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +8579,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +6356,"Normal review of systems template. The case denies fever, fatigue, weakness, weight gain or weight loss.",25 +2614," Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",38 +2740, Laparoscopic cholecystectomy with cholangiogram.,14 +7687,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3853," Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",11 +8867,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +5954,"Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +2858, Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,15 +3077," Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.",38 +9859,Dietary consultation for gestational diabetes.,9 +1228, Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,33 +4886,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",10 +113," Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +7971,Consultation for left foot pain.,4 +11509,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1642, Phacoemulsification with posterior chamber intraocular lens - Sample/Template.,38 +7393,Chiropractic IME with answers to questions from Insurance Company.,4 +4469,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The client was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 +10377,Patient scheduled for laparoscopic gastric bypass.,2 +2709," Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",38 +9446,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +6610,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +10213,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +8402,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2738," The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. ",38 +6450,Encephalopathy related to normal-pressure hydrocephalus.,30 +10540,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +5391,"Fever, otitis media, and possible sepsis.",29 +12499,Autopsy - Asphyxia due to ligature strangulation.,1 +1274," New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",5 +46," Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +2321," Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.",38 +6087,Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 +10249,Significant ache in left lower jaw.,7 +2111," Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.",5 +8811,Occupational medicine consult with questions-answers and records review.,18 +9103,Preop evaluation regarding gastric bypass surgery.,2 +416, Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +10769,Autopsy - Homicide - Blunt force cranial trauma,1 +7467,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +2376," Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.",38 +3451," Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan.",3 +7903,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no discomfort that radiates from her back into her legs. She has had no associated weakness.",30 +4678,"Still having diarrhea, decreased appetite.",35 +12439,Autopsy - Homicide - Blunt force cranial trauma,1 +7622,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6891,Osteoarthritis of the right knee. Right knee joint steroid injection.,28 +7796,Chiropractic IME with answers to questions from Insurance Company.,4 +8688,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +12291,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10430,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2438, Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. ,14 +11411,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +6600,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The client fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +10272,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +12108,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +3696," Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",12 +3562, Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week. ,15 +4741,"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient therapy and increased mood lability.",32 +5942,"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +5798,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +10087,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +5066,Ophthalmology followup visit note.,26 +10150,"Specimen labeled ""sesamoid bone left foot"".",19 +11574,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +11776,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5322,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +3746, Duplex ultrasound of legs,3 +2604, Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.,27 +5864,"Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 +5310,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 +4659,A 65-year-old man with chronic prostatitis returns for recheck.,39 +8507,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +8421,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +11407,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +6046,Letter to the client to let him know about his abnormal cholesterol test results.,20 +636," Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.",3 +10996,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10976,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +4484,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 +1037, The patient underwent a total vaginal hysterectomy.,10 +8637,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +491," Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.",14 +7907,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +9610,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10027,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +10916,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10466,Work restrictions and disability evaluation,4 +11692,Mother states he has been wheezing and coughing.,0 +5003,Vaginal discharge with a foul odor.,24 +3052," A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.",3 +7548,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7459,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +2838," Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.",39 +1598, She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,38 +4854,"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 +8497,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +8573,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +11348,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +11036,Mother states he has been wheezing and coughing.,0 +2341," Acute foot or ankle sprain, possible small fracture.",31 +1452, Patient today with multiple issues. ,35 +9250,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +8696,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +3993," Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",15 +8839,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +1769, A 37 year-old female with twin pregnancy with threatened premature labor.,33 +1570, An example/template for a routine normal male physical exam.,15 +8541,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12140,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9948,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +10299,Completion thyroidectomy with limited right paratracheal node dissection.,13 +6577,Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,23 +4074,Patient in ER with upper respiratory infection,15 +2455," 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.",26 +170," Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.",35 +9613,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +138," Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",39 +8647,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +3873, She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.,24 +11340,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +6176,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +1535," The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",5 +2021," CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.",33 +11262,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +1098," Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",5 +9337,Elevated cholesterol and is on medication to lower it.,9 +11209,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +12652,Patient presents for care of suspected rheumatoid arthritis.,34 +11869,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10464,"Records review. The patient developed shooting ache about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +5317,"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.",25 +5228,"Head injury, anxiety, and hypertensive emergency.",29 +3132, History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.,15 +5803,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +4105,"Right shoulder impingement syndrome, right suprascapular neuropathy.",22 +6261,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +1706," Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.",5 +1345, An example/template for a routine normal female physical exam.,5 +2622," Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ",14 +3363, Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,35 +8151,Consultation for wrist pain.,4 +4386,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 +6107,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +10134,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +8808,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +11093,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3028," Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",38 +11431,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +132, A 60-year-old female presents today for care of painful calluses and benign lesions.,35 +9463,Mother states he has been wheezing and coughing.,0 +1657, HCT: Subdural hemorrhage.,22 +5563,A lady was admitted to the hospital with chest ache and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,10 +2072, MRI demonstrated right contrast-enhancing temporal mass.,35 +5090,"The skin biopsy was performed on the right ankle and right thigh. The case was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +6512,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +1648, One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 +6256,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5341,Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,23 +3761, Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.,27 +2994," Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",38 +105, Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,39 +8290,Dietary consultation for carbohydrate counting for type I diabetes.,9 +7406,A 23-year-old white female presents with complaint of allergies.,0 +5088,"The skin biopsy was performed on the right ankle and right thigh. The case was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +12608,A sample note on Rheumatoid Arthritis,34 +5584,Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.,10 +9910,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +1025, Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.,14 +9640,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6749,CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,23 +4631,Patient with immune thrombocytopenia,16 +6743,Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 +4019,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +11128,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9881,Mother states he has been wheezing and coughing.,0 +7644,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11383,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +2997," Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",27 +1285," Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +12359,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +9083,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9982,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +5470,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +6392,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",16 +9750,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +535, Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,39 +5743,CT scan of the abdomen and pelvis without and with intravenous contrast.,21 +7838,A 23-year-old white female presents with complaint of allergies.,0 +6691,"A 7-year-old white male started to complain of ache in his fingers, elbows, and neck. This patient may have had reactive arthritis.",29 +6493,Preoperative visit for weight management with laparoscopic gastric banding,2 +11350,Chiropractic IME with answers to questions from Insurance Company.,18 +4713,"Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.",10 +5988,Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 +9706,A sample note on Rheumatoid Arthritis,34 +6131,Parotidectomy procedure,11 +11446,Encephalopathy related to normal-pressure hydrocephalus.,30 +9680,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10725,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +11113,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +686, Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,24 +8276,Initial evaulation - neck and back pain.,4 +8723,Work restrictions and disability evaluation,18 +8450,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +930, Pulmonary function test. Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy.,3 +1493," Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.",14 +11845,A sample note on Rheumatoid Arthritis,34 +10678,Dietary consultation for gestational diabetes.,9 +8607,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +6851,Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.,26 +2551, The patient has been suffering from intractable back and leg pain.,27 +10850,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +7831,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +12025,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11104,Patient presents for care of suspected rheumatoid arthritis.,34 +10784,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +8005,The case underwent an overnight polysomnogram.,36 +5599,"Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.",23 +2568," Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.",32 +4101,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 +10865,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +6846,Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe.,28 +8557,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +1201, Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.,38 +1684," Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",14 +10616,Chiropractic IME with answers to questions from Insurance Company.,4 +1405," Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.",38 +10852,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +11380,MRI report Cervical Spine (Chiropractic Specific),4 +3769," 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.",33 +936, Work restrictions and disability evaluation ,18 +1799," Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.",38 +814, Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,35 +1347," An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething.",15 +3338," Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.",38 +7779,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +6212,CT Abdomen & Pelvis W&WO Contrast,21 +10170,Consultation for left foot pain.,4 +2667," Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.",14 +378, MRI C-spine: C4-5 Transverse Myelitis.,27 +4382,Bilateral renal ultrasound.,33 +11891,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3306, Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,27 +6651,"Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",11 +2286," Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, ",5 +3571, Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,22 +6664,Belly button piercing for insertion of belly button ring.,6 +7182,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +2032," Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +11732,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +4262,"The case is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.",32 +7749,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +5279,The client underwent a total vaginal hysterectomy.,10 +4280,Occupational medicine consult with questions-answers and records review.,18 +1010, Patient with immune thrombocytopenia,35 +6553,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +2279, MRI Brain - Olfactory groove meningioma.,22 +639, Incision and drainage (I&D) of buttock abscess. ,8 +2250, Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.,27 +7012,Dietary consultation for carbohydrate counting for type I diabetes.,9 +3092, Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 +2006, Pain. Three views of the right ankle. Three views of the right ankle are obtained.,33 +7828,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +1910, Right pontine pyramidal tract infarct.,22 +9071,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +12342,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7144,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +3387," Pain and swelling in the right foot, peroneal tendon tear.",33 +8516,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +10903,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +3356," Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. ",39 +5822,Underwent tonsillectomy and adenoidectomy two weeks ago.,25 +5043,Psychiatric Assessment of a client with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 +10595,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10345,The client has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +6933,"Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",31 +6118,She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 +8950,Consultation for left foot pain.,4 +7875,Is it BNP or BMP?,19 +4366,Patient dropped a weight on the dorsal aspects of his feet.,31 +12170,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3287, Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,39 +538, The patient states that he feels sick and weak.,35 +12120,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +8394,Work restrictions and disability evaluation,4 +11157,A sample note on Rheumatoid Arthritis,34 +10205,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +1605," A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +6804,"Lumbar epidural steroid injection, L5-S1. Low back pain.",28 +12173,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12061,Autopsy of a white female who died of acute combined drug intoxication.,1 +11602,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +353," Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.",15 +7248,A sample note on Rheumatoid Arthritis,34 +5239,Patient with immune thrombocytopenia,35 +8905,"Followup diabetes mellitus, type 1.",13 +4460,"Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to clinical therapy, severe anemia, and symptomatic fibroid uterus.",10 +9729,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6549,"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.",16 +842," Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. ",5 +7666,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +2996, Migraine headache - The patient was seen in the urgent care.,15 +3900, Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.,25 +9867,Is it BNP or BMP?,19 +3398, CT Scan of brain without contrast.,33 +7065,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 +1026," This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +11764,Cause of death - Anoxic Encephalopathy,1 +10686,Is it BNP or BMP?,19 +2758," Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. +",39 +12042,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +576, Right carpal tunnel release.,27 +2462," Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.",38 +11155,A sample note on Rheumatoid Arthritis,34 +731, Dietary consultation for diabetes during pregnancy.,5 +7227,Is it BNP or BMP?,19 +4485,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 +6331,"Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.",26 +11704,Autopsy - Homicide - Blunt force cranial trauma,1 +2233, Superior labrum anterior and posterior lesion repair.,38 +2319, Pain management sample progress note.,28 +11359,Mother states he has been wheezing and coughing.,0 +7122,Caudal epidural steroid injection without fluoroscopy.,28 +592," Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.",27 +11309,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +1502," A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",15 +11076,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6055,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient therapy with nitrofurantoin.,10 +5619,The client is being discharged for continued hemodialysis and rehab.,21 +1826," Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",33 +8773,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +2255," Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.",27 +9717,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +12247,Autopsy - Homicide - Blunt force cranial trauma,1 +4542,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",35 +9642,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12394,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10831,Autopsy of a white female who died of acute combined drug intoxication.,1 +924, The patient is being referred for evaluation of diabetic retinopathy.,20 +152, Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,16 +9445,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +6726,L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,28 +375," A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",29 +6968,"A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.",31 +8899,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +663," Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",10 +7563,A 23-year-old white female presents with complaint of allergies.,0 +12018,Consultation for left foot pain.,4 +3369, MRI T-spine and CXR - Aortic Dissection.,27 +1313," 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.",38 +10158,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +9753,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11339,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +7646,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4464,Patient in ER with upper respiratory infection,12 +3886, A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7051,Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back discomfort referring into the left side.,28 +4970,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +1060," EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",22 +6283,"She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.",28 +8837,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +1711," Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +7239,Mother states he has been wheezing and coughing.,0 +4836,"Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 +12606,A sample note on Rheumatoid Arthritis,34 +10997,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6688,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +4394,Brain CT and MRI - suprasellar mass (pituitary adenoma),33 +1939," Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.",14 +6160,Significant ache in left lower jaw.,7 +12454,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +8526,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +5038,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The client is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +10761,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +5850,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +9218,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4049,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 +3905," A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +2486, Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,11 +9848,A 23-year-old white female presents with complaint of allergies.,0 +5157,A 3-year-old abrupt onset of cough and increased work of breathing.,29 +1878, History and Physical for right ankle sprain,27 +10423,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +10845,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +11008,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8216,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 +9344,Patient presents for care of suspected rheumatoid arthritis.,34 +3372," Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",15 +3461, Excision of bilateral chronic hydradenitis.,38 +2703," Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location. ",38 +10568,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +1749, Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,3 +162, Axial images through the cervical spine with coronal and sagittal reconstructions.,27 +12631,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10217,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +5457,Bilateral vasovasostomy surgery sample.,39 +7906,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +1337," Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",23 +8456,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +1752," Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",35 +8161,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +4063,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,10 +5104,Patient is here to discuss possible open lung biopsy.,35 +9192,Consult for laparoscopic gastric bypass.,2 +1601," Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.",38 +6065,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +10444,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4894,A sample note on bilateral myringotomy tubes,11 +4309,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 +2625," Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue",5 +2443, Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis,5 +10767,Autopsy - Homicide - Blunt force cranial trauma,1 +5796,Mother states he has been wheezing and coughing.,0 +3950, Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition.,24 +5300,Fifth disease with sinusitis,35 +2993," Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.",3 +12444,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +7235,"Specimen labeled ""sesamoid bone left foot"".",19 +9856,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4881,"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.",39 +5051,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.,24 +10965,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1048, Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,38 +6527,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,12 +397," Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.",14 +10279,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4646,"CT abdomen without contrast and pelvis without contrast, reconstruction.",21 +124," Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.",3 +11683,"Specimen labeled ""sesamoid bone left foot"".",19 +4845,Excision of penile skin bridges about 2 cm in size.,39 +1944, The patient is status post C3-C4 anterior cervical discectomy and fusion.,22 +6223,Admission Psychiatric Evaluation,32 +5902,"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",16 +9165,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +6386,"Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 +8267,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +3429, Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,38 +8949,Consultation for left foot pain.,4 +4008,Followup of moderate-to-severe sleep apnea. The client returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,15 +11812,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12299,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5748,One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 +5253,"Clogged AV shunt. The client complains of fatigue, nausea, vomiting and fever.",21 +10967,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6098,"This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.",32 +724, Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.,14 +672," Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",21 +3759, This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,5 +8496,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +7385,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +6421,An example normal physical exam,25 +942, Inguinal hernia hydrocele repair.,38 +9762,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3295, Consultation - an 87-year-old white female with weakness and a history of polymyositis.,5 +9797,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6359,"Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 +12012,"Specimen labeled ""sesamoid bone left foot"".",19 +5958,"A 49-year-old female with ankle ache times one month, without a specific injury.",31 +12660,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1537, Patient with intermittent episodes of severe nausea and abdominal pain.,5 +2921, Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,3 +10997,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1760," Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.",14 +9458,Mother states he has been wheezing and coughing.,0 +671," Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",38 +9701,A sample note on Rheumatoid Arthritis,34 +2589, Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,27 +3953, A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,24 +1143," Follow up consultation, second opinion, foreskin.",35 +967," Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.",3 +11988,Occupational medicine consult with questions-answers and records review.,18 +2420," Colonoscopy, conscious sedation, and snare polypectomy.",38 +9269,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +9015,A sample note on Rheumatoid Arthritis,34 +3135," The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.",15 +11670,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +11481,Qualified healthcare evaluation report of a patient with back pain.,18 +23, Common description of colonoscopy,14 +8039,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +12536,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +1688, Debridement left ischial ulcer.,14 +6379,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +2548," Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",38 +4062,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,10 +5654,"Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",26 +2523, Hand dermatitis.,35 +6302,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +2670, The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.,35 +1975, MRI report Cervical Spine (Chiropractic Specific),4 +568, SPARC suburethral sling due to stress urinary incontinence.,38 +1609, A 21-channel digital electroencephalogram was performed on a patient in the awake state.,22 +2685," Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. ",23 +5567,"Congestion, tactile temperature.",29 +1646," Intractable epilepsy, here for video EEG.",5 +6206,Right pleural effusion and suspected malignant mesothelioma.,16 +5451,"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",29 +1209," Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.",38 +1590, Bladder instillation for chronic interstitial cystitis.,39 +11545,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1460," Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. ",38 +2029," Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.",38 +3324, Headache. Right frontal lobe glioma.,5 +8603,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +8502,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2095, Parotidectomy procedure,38 +9593,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5490,Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,26 +3413, Initial evaulation - neck and back pain.,4 +5993,A 21-channel digital electroencephalogram was performed on a client in the awake state.,36 +10664,Evaluation for bariatric surgery.,2 +1656, Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted.,3 +10135,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +12211,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +5761,The client with continued problems with her headaches.,25 +9330,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4007,MRI Brain: Thrombus in torcula of venous sinuses.,33 +9817,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10267,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +10504,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +10460,Patient presents for therapy of suspected rheumatoid arthritis.,34 +3245, CT Brain: Midbrain hemangioma,22 +83, Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,39 +10893,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11977,Dietary consultation for gestational diabetes.,9 +8327,"Total thyroidectomy. The case is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +2246," Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",15 +12135,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7866,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +393, Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +4000,"Bilateral Mammogram, (abnormal) additional views requested",33 +1416, Patient with stable expressive aphasia and decreased vision.,22 +4946,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +11444,Consult for laparoscopic gastric bypass.,2 +6661,"Discharge summary of client with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",16 +7157,Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.,25 +10317,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +661," Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",27 +1820," Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",38 +7939,"Followup diabetes mellitus, type 1.",13 +7048,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient therapy with nitrofurantoin.,12 +10709,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10209,MRI report Cervical Spine (Chiropractic Specific),4 +11295,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +11362,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +5539,"Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",23 +2933, Consultation for right shoulder pain.,27 +9249,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2742," Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.",3 +1687, A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. ,5 +9148,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +11493,Initial evaulation - neck and back pain.,4 +12207,Is it BNP or BMP?,19 +11550,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10437,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +7592,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11289,Dietary consultation for gestational diabetes.,9 +3382," Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression.",10 +12145,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11056,A sample note on Rheumatoid Arthritis,34 +9771,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1876, Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,27 +8939,Chiropractic IME with answers to questions from Insurance Company.,18 +4960,Lumbar epidural steroid injection for lumbar radiculopathy.,28 +6538,"Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye",26 +951," Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.",38 +11505,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +4901,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3329, Prostate Brachytherapy - Prostate I-125 Implantation,16 +3555," The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.",22 +2935," Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.",38 +1084, Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 +3614, Diagnosis of benign rolandic epilepsy.,20 +7130,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +1953, Ultrasound of pelvis - menorrhagia.,33 +11998,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2410, Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,5 +8532,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +12453,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3520, Colonoscopy due to hematochezia and personal history of colonic polyps.,14 +8037,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +8547,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +389," A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.",38 +5186,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",21 +9643,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7268,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5386,"Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum.",24 +5501,Circumcision in an older person,39 +11703,Autopsy - Homicide - Blunt force cranial trauma,1 +9736,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4567,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent identification of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +1727, Open reduction and internal fixation of left distal radius.,38 +12391,Chiropractic IME with answers to questions from Insurance Company.,4 +9878,Mother states he has been wheezing and coughing.,0 +3601, HDR Brachytherapy,33 +11376,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +1255," Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.",24 +7183,Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 +9085,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9033,MRI report Cervical Spine (Chiropractic Specific),4 +4098,Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +11204,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +11535,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +5678,"Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",10 +1471," Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",16 +1594," Sample normal ear, nose, mouth, and throat exam.",15 +11320,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11737,Autopsy of a white female who died of acute combined drug intoxication.,1 +2254," Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.",15 +7193,Well-child check and school physical.,29 +8911,"Followup diabetes mellitus, type 1.",13 +8094,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +6702,Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 +8987,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +12003,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +356," Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",22 +1897, Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.,38 +3316," Patient with suspected nasal obstruction, possible sleep apnea. ",5 +8117,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +8970,Mother states he has been wheezing and coughing.,0 +8547,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +655," Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.",3 +361, Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,38 +3177," Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",38 +8387,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +8404,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10231,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +11702,Autopsy - Homicide - Blunt force cranial trauma,1 +949, This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,15 +9890,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2966, Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 +5178,"Left flank pain, ureteral stone.",39 +2195, GI Consultation for Chrohn's disease.,14 +6245,Patient presents with a chief complaint of chest ache admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 +1759," CT abdomen and pelvis without contrast, stone protocol, reconstruction.",14 +4724,A sample note on Conjunctivitis (Pink Eye).,26 +3262," Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ",15 +6808,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 +3651," 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.",5 +8443,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +742," Lateral and plantar condylectomy, fifth left metatarsal.",27 +1863," Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. ",5 +1236, Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.,14 +6236,"A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.",10 +2515, Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,38 +5251,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",12 +6156,Preop evaluation regarding gastric bypass surgery.,2 +6566,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +749," Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. +",2 +332, Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,38 +8104,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +600, A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 +10896,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12212,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4513,"Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the client has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.",24 +7341,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +184, The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. ,27 +11861,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1744," Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ",5 +1380, An example/template for a routine normal female physical exam.,25 +639, Incision and drainage (I&D) of buttock abscess. ,8 +1464," Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 +2901, Chiropractic Evaluation for neck and low back pain following a car accident.,4 +9671,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6407,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +7832,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +7426,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5455,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +6070,Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,10 +10058,Evaluation for bariatric surgery.,2 +5215,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The case was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 +1854," Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm",33 +8929,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +5517,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +8640,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3186, Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.,27 +6683,"Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",31 +67," Patient with hypertension, dementia, and depression.",15 +11739,Autopsy of a white female who died of acute combined drug intoxication.,1 +211," Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis. +",14 +1851, Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,24 +7923,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +5549,"Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",31 +11337,"Followup diabetes mellitus, type 1.",13 +1649," Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.",38 +9108,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +5553,"Sample normal ear, nose, mouth, and throat exam.",11 +2389, Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,38 +7171,"The case with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +1429, Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,27 +2290, Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy. ,38 +10800,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +4745,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +3125, Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.,27 +7223,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +1877, Patient presents with complaint of lump in the upper outer quadrant of the right breast,16 +5109,"School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 +1436, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,27 +7415,Is it BNP or BMP?,19 +1348," Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.",35 +7474,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +3618, Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. ,7 +11270,A 23-year-old white female presents with complaint of allergies.,0 +5756,A 9-month well-child check.,29 +7920,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +3065," 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.",38 +11721,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +7599,Mother states he has been wheezing and coughing.,0 +3137," Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.",27 +9479,Autopsy - Homicide - Blunt force cranial trauma,1 +4244,"The case has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 +3055, The patient admitted with palpitations and presyncope.,3 +10338,Preoperative visit for weight management with laparoscopic gastric banding,2 +4318,Whole body radionuclide bone scan due to prostate cancer.,33 +979, Repair of upper lid canalicular laceration - Sample/Template.,38 +3902, Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.,18 +4328,"Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.",22 +11281,Occupational medicine consult with questions-answers.,18 +9609,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7764,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +10386,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +7350,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10488,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2334," Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.",3 +5053,"The client presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",24 +5737,"Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",11 +3975," Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. +7. Microscopic dissection.",23 +722," Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis.",5 +540," Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",38 +12236,Mother states he has been wheezing and coughing.,0 +6834,The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.,26 +3217, 2-month-old female - increased work of breathing.,3 +4902,"Patient had a recurrent left arm discomfort after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",12 +4363,Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 +10899,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +6791,"Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 +4380,"Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The case appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",24 +9890,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +5014,Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 +1142," EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +9153,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +6442,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.,16 +7538,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +134, External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 +12300,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4535,Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,14 +1268," C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",27 +3103," A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.",15 +6718,Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 +9813,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6819,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +1390, Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +10185,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8543,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10989,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1669, Blepharoplasty procedure,6 +3444," 5-month recheck on type II diabetes mellitus, as well as hypertension.",35 +7441,Autopsy - Homicide - Blunt force cranial trauma,1 +10164,Blepharoplasty procedure,6 +6875,"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.",23 +4077,MRI Cervical Spine without contrast.,33 +12078,Cause of death - Anoxic Encephalopathy,1 +5458,Bilateral vasovasostomy surgery sample.,39 +4763,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",35 +7770,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +11335,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +8322,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +4979,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +666, Open reduction and internal fixation of left tibia.,27 +6623,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +11205,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +12035,MRI report Cervical Spine (Chiropractic Specific),4 +10394,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +5500,"Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 +2341," Acute foot or ankle sprain, possible small fracture.",31 +2178, Preop evaluation regarding gastric bypass surgery.,2 +6786,Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib ache related to a herniated nucleus pulposus at T8-T9.,23 +3150," Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.",22 +8081,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +6513,"Evaluate for retroperitoneal hematoma, the case has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",21 +286, Sample Radiology report of knee (growth arrest lines).,33 +5780,Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.,31 +10872,Cause of death - Anoxic Encephalopathy,1 +6361,Repair of ruptured globe involving posterior sclera - Sample/Template.,26 +12489,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +5469,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +11642,Is it BNP or BMP?,19 +3572, Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.,3 +270, Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,33 +8641,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2204, Left supraorbital deep complex facial laceration measuring 6x2 cm. Plastic closure of deep complex facial laceration measuring 6x2 cm. The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.,38 +960," Chest, Single view post OP for ASD (Atrial Septal Defect).",3 +4991,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +10476,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3526, Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,22 +1186, 2-D Echocardiogram,3 +11559,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +882," Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.",5 +731, Dietary consultation for diabetes during pregnancy.,5 +10654,A 23-year-old white female presents with complaint of allergies.,0 +5443,Hand dermatitis.,8 +2345," Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",10 +5605,"Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",26 +9290,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1110, Nephrology office visit for followup of CKD.,25 +907, A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 +4558,"Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",22 +7444,A sample note on Rheumatoid Arthritis,34 +4740,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",26 +5903,"Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",10 +11789,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9844,A 23-year-old white female presents with complaint of allergies.,0 +2756, The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +7335,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4651,She was admitted following an overdose of citalopram and warfarin. The case has had increasing depression and has been under stress as a result of dissolution of her second marriage.,32 +87, Initial evaulation - neck and back pain.,5 +5661,1-year well child check.,29 +7810,Follow up update on client with left carotid angioplasty and stent placement.,20 +1408, 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. ,38 +8757,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +2144," Followup diabetes mellitus, type 1.",15 +3965, Patient with morbid obesity.,15 +8306,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 +11617,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4819,"Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +3565," Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.",39 +5436,Psychiatric consultation for management of ache medications.,32 +2206, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,38 +5112,"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 +1258," Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",27 +9868,Is it BNP or BMP?,19 +9648,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4252,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +7581,Is it BNP or BMP?,19 +215, ,37 +2696," Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.",38 +11249,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1195, Emergency cesarean section.,24 +7010,Blepharoplasty procedure,26 +2819, An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 +3202, Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation ,3 +3478," A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection.",5 +6324,Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement.,12 +1162, Endovascular Brachytherapy (EBT),3 +2212, Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 +12484,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +9606,Patient presents for care of suspected rheumatoid arthritis.,34 +8106,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +4954,Vitrectomy under local anesthesia.,26 +2994," Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",38 +7039,"Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 +11458,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8034,Letter to the client to let him know about his abnormal cholesterol test results.,20 +4752,"Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder ache and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",35 +5829,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +4053,Bilateral Myringotomy with placement of PE tubes,11 +5986,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear discomfort resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",11 +3608, Right subclavian triple lumen central line placement,3 +3852," Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.",3 +6708,Qualified medical evaluation report of a client with back pain.,18 +5509,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +9913,Work restrictions and disability evaluation,4 +6149,"The patient has had abdominal ache associated with a 30-pound weight loss and then developed jaundice. He had epigastric ache and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.",10 +8103,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +437," Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.",5 +1966," A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",38 +8254,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +11684,Mother states he has been wheezing and coughing.,0 +7859,Occupational medicine consult with questions-answers.,18 +4556,"Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",22 +11574,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +8096,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +3025, Chronic snoring in children,15 +3601, HDR Brachytherapy,33 +5961,Lower lid blepharoplasty.,26 +6937,"Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.",28 +8015,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +2859, Fall/loss of consciousness.,22 +7916,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +5898,"The client is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",10 +2146, Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,33 +6045,Letter to the case to let him know about his abnormal cholesterol test results.,20 +5819,Discharge summary of a case with depression and high risk behavior.,32 +9787,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8270,Incision and drainage of right buccal space abscess and teeth extraction.,7 +2976, A 12-year-old young man with sinus congestion.,5 +2885," Coronary artery bypass grafting (CABG) x4. Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.",3 +8506,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +11965,Work restrictions and disability evaluation,18 +7463,Autopsy of a white female who died of acute combined drug intoxication.,1 +1891, CT of the facial bones without contrast due to hit in nose.,33 +8431,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +5218,"Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",21 +4778,"Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",39 +8492,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +11741,Autopsy of a white female who died of acute combined drug intoxication.,1 +11414,Consult for laparoscopic gastric bypass.,2 +11411,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +1398," Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.",27 +5040,Psychosocial Evaluation of case before kidney transplant.,32 +3457," Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.",3 +11717,A sample note on Rheumatoid Arthritis,34 +2870, Sample progress note - Gen Med.,15 +9884,Mother states he has been wheezing and coughing.,0 +5329,Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 +10881,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +4338,"Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +11648,Dietary consultation for diabetes during pregnancy.,9 +1932," Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. ",11 +11118,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9670,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6870,"Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",26 +11606,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7535,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +4229,Resting Myoview and adenosine Myoview SPECT,33 +1342, Marked right hydronephrosis without hydruria. ,21 +11686,Mother states he has been wheezing and coughing.,0 +1970, Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,33 +11316,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no discomfort that radiates from her back into her legs. She has had no associated weakness.",30 +9255,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +4491,Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,23 +262," Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.",5 +8342,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +6679,Acromioclavicular joint injection,28 +9298,Autopsy - Asphyxia due to ligature strangulation.,1 +1403, Psychiatric History and Physical - Patient with schizoaffective disorder.,32 +6869,"Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",11 +5429,The case was referred due to concerns regarding behavioral acting out as well as encopresis.,32 +878, Complete eye examination - Normal eye and vision exam.,5 +8214,Belly button piercing for insertion of belly button ring.,6 +1130, Common description of colonoscopy,38 +3885," Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.",38 +3273, The patient was running and twisted her right ankle - right ankle sprain.,27 +1096," Pain and swelling in the right foot, peroneal tendon tear.",31 +235," Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",38 +7957,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +5836,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 +173," Followup diabetes mellitus, type 1.",35 +7521,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11797,Autopsy - Asphyxia due to ligature strangulation.,1 +6312,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +10481,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +7404,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +3228," Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.",5 +2882, Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,22 +5007,"The case is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",11 +8327,"Total thyroidectomy. The case is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +4873,Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 +10644,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +10374,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +328," Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",38 +4112,Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,11 +6321,Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 +7476,Cause of death - Anoxic Encephalopathy,1 +9095,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +7370,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +11335,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +2349, Dietary consultation for gestational diabetes.,35 +2464, Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. ,5 +2668, Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.,38 +441," CT abdomen without contrast and pelvis without contrast, reconstruction.",21 +2514," The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ",38 +1196," Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",28 +1002," Head injury, anxiety, and hypertensive emergency.",29 +11389,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +4530,Sample for Neuropsychological Evaluation,32 +5467,"C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",23 +3122, Common description of colonoscopy,38 +6347,"Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The case 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.",26 +1980, MRI right ankle.,33 +1417," Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",23 +7177,Vaginal discharge with a foul odor.,12 +11153,A sample note on Rheumatoid Arthritis,34 +9147,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +7661,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1068, Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.,3 +5221,Adenotonsillectomy. Adenotonsillitis with hypertrophy. The client is a very nice client with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +5138,A 23-year-old white female presents with complaint of allergies.,35 +4645,"CT abdomen without contrast and pelvis without contrast, reconstruction.",21 +6863,"Onychomycosis present, #1 right and #1 left.",31 +8328,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +6624,"Patient with a history of PTSD, depression, and substance abuse.",32 +11197,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +5319,"A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",29 +2415," Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.",38 +695," Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ",11 +8664,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +1978, Inguinal herniorrhaphy. A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ,38 +4518,A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,24 +2752," 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.",24 +10543,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1762, A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11602,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9160,Occupational medicine consult with questions-answers and records review.,18 +1431, 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.,12 +649, Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,38 +6391,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",16 +5860,Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 +694," Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",31 +8223,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6439,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,29 +8419,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +6147,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +6485,Falls at home. Anxiety and depression. The case had been increasingly anxious and freely admitted that she was depressed at home.,32 +6565,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +4831,Consult and Spinal fluid evaluation in a 15-day-old,29 +11489,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +9518,Autopsy of a white female who died of acute combined drug intoxication.,1 +2240, CT Abdomen & Pelvis W&WO Contrast,21 +6115,A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 +6936,CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 +477," The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.",15 +9579,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12534,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8822,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +11252,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +4339,"Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +10029,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +2134, Parotidectomy procedure,11 +4516,Psychiatric evaluation for major depression without psychotic features.,32 +2912, A 19-year-old right-handed male injured in a motor vehicle accident.,20 +2087," Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +1598, She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,38 +1802, Bilateral temporal artery biopsy. Rule out temporal arteritis.,23 +4993,"Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.",23 +1095," Open reduction, nasal fracture with nasal septoplasty.",38 +3947," Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ",39 +3830," History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.",14 +11146,A sample note on Rheumatoid Arthritis,34 +7959,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +4437,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",35 +9208,Evaluation for chronic discomfort program,4 +12161,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4756,Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,28 +3197," Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.",12 +1470," Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.",5 +8657,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +268," Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.",5 +2459," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +11488,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +1880, Post-surgical medical management; right total knee replacement.,5 +12616,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +4046,CT Brain: Midbrain hemangioma,33 +10587,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +7188,Evaluation and recommendations regarding facial rhytids.,8 +3744, Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,3 +9585,Autopsy - Asphyxia due to ligature strangulation.,1 +2494, MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,33 +2759, Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,5 +8351,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3218, GI Consultation for Chrohn's disease.,5 +5128,"Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",10 +1489, A white female with a history of fevers.,10 +9442,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +6450,Encephalopathy related to normal-pressure hydrocephalus.,30 +2432," Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)",35 +907, A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 +12162,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3665, Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.,11 +3373," Questionable foreign body, right nose. Belly and back pain. Mild constipation.",15 +6310,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The case is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",12 +2020," Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.",38 +8465,Occupational medicine consult with questions-answers and records review.,18 +6837,"Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the case ended up taking a total of six Ecstasy tablets.",12 +11255,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +4451,"Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",24 +5504,A client with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,16 +7, Patient with increased shortness of breath of one day duration.,15 +6759,"Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",31 +10257,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +154," New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",27 +10846,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +4193,"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +10887,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +422," Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. ",38 +12345,Work restrictions and disability evaluation,4 +3384," Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",27 +7136,Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 +11361,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +10886,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +3401, Open radical retropubic prostatectomy with bilateral lymph node dissection.,38 +126," Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.",3 +4288,Overactive bladder with microscopic hematuria.,39 +8758,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +1410, Elevated PSA with nocturia and occasional daytime frequency.,35 +533," Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",35 +3604, An example/template for a routine normal male ROS.,15 +10184,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +5381,"Discharge Summary of a client with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.",10 +12630,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11481,Qualified healthcare evaluation report of a patient with back pain.,18 +1282, Unilateral transpedicular T11 vertebroplasty.,27 +7871,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +11319,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2567," Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical",39 +1882, Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea.,38 +7331,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7352,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11742,Autopsy of a white female who died of acute combined drug intoxication.,1 +3581," Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.",38 +2235," Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure.",3 +12274,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +5263,"Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",11 +5461,Dietary consultation for diabetes during pregnancy.,9 +820," This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. ",35 +7571,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +10768,Autopsy - Homicide - Blunt force cranial trauma,1 +6909,Plantar Fascia Injection,28 +2063, Bilateral carotid ultrasound to evaluate pain.,3 +8525,Chiropractic IME with answers to questions from Insurance Company.,20 +8788,Is it BNP or BMP?,19 +7266,Cause of death - Anoxic Encephalopathy,1 +7543,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7961,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +2512," The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",38 +9975,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +2409, Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 +1525, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,5 +8257,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +4158,"A complex closure and debridement of wound. The client is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",23 +5277,The client underwent a total vaginal hysterectomy.,10 +6262,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +1539," Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs",27 +10855,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +10877,Cause of death - Anoxic Encephalopathy,1 +6748,CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,23 +12001,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +11178,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +699, Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 +1082, Cystoscopy. Transurethral resection of the prostate.,39 +5419,Patient referred for narrow angles and possible associated glaucoma.,26 +9759,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +336, Neurologic consultation was requested to evaluate her seizure medication and lethargy.,5 +10806,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +129, Incision and drainage (I&D) of gluteal abscess. Removal of pigtail catheter. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,38 +4615,Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,11 +7911,"Patient suffers from neck and lower back discomfort radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +1019, Decreased ability to perform daily living activities secondary to right knee surgery.,27 +7085,"Sample normal ear, nose, mouth, and throat exam.",25 +10661,Work restrictions and disability evaluation,18 +10089,Occupational medicine consult with questions-answers and records review.,18 +4920,Frontal and lateral views of the hip and pelvis.,29 +621, Followup on chronic kidney disease.,21 +9223,Cause of death - Anoxic Encephalopathy,1 +5653,A white female with a history of fevers.,10 +8676,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +9345,Patient presents for care of suspected rheumatoid arthritis.,34 +6675,Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 +6827,"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 +5547,Marked right hydronephrosis without hydruria.,21 +6954,Initial evaulation - neck and back pain.,4 +645, Thallium stress test for chest pain.,33 +5619,The client is being discharged for continued hemodialysis and rehab.,21 +10930,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2146, Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,33 +1763," Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 +12205,Is it BNP or BMP?,19 +8716,A 23-year-old white female presents with complaint of allergies.,0 +2189, Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 +5194,Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,24 +2504," Aortoiliac occlusive disease. Aortobifemoral bypass. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.",3 +8943,Chiropractic IME with answers to questions from Insurance Company.,18 +5532,A female with unknown gestational age who presents to the ED after a suicide attempt.,12 +1205, Sample female exam and review of systems.,15 +2115, Right Achilles tendon rupture.,27 +9699,A sample note on Rheumatoid Arthritis,34 +10897,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +427," Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management",15 +3469, Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 +1669, Blepharoplasty procedure,6 +4332,"Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",10 +3575," Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.",24 +6180,"Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",21 +8063,Significant ache in left lower jaw.,7 +8173,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +2699, She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,5 +1450," Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. ",38 +3058, Blood in urine - Transitional cell cancer of the bladder.,39 +1630," The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",32 +11621,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7233,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +12550,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +662," Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ",38 +6132,Parotidectomy procedure,11 +1782, Revision right total knee arthroplasty. Right failed total knee arthroplasty.,27 +9407,A 23-year-old white female presents with complaint of allergies.,0 +7847,Work restrictions and disability evaluation,18 +2500," Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.",27 +5891,Autopsy - Homicide - Blunt force cranial trauma,1 +12322,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8759,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +2133," Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",38 +6118,She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 +5191,"Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The client works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.",31 +8471,Occupational medicine consult with questions-answers and records review.,18 +2485," Request for consultation to evaluate stomatitis, possibly methotrexate related.",15 +6593,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 +12456,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8936,Chiropractic IME with answers to questions from Insurance Company.,18 +12567,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6865,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +11345,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +3249, Psychiatric Consultation of patient with dementia.,5 +5715,Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 +10055,Work restrictions and disability evaluation,18 +5874,"A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",29 +11478,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12341,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12118,Patient presents for therapy of suspected rheumatoid arthritis.,34 +9566,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3995, Coil embolization of patent ductus arteriosus.,38 +7110,Autopsy - Asphyxia due to ligature strangulation.,1 +2878, Stage I and II neuromodulator.,38 +1303," Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.",38 +8449,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9405,A 23-year-old white female presents with complaint of allergies.,0 +9284,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +5184,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",21 +3006," Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.",38 +5085,"Left neck dissection. Metastatic papillary cancer, left neck. The client had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.",16 +7210,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +8279,"Female with intermittent rectal bleeding, not associated with any weight loss. The client is chronically constipated.",20 +1767," Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.",39 +6833,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +1123," Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.",3 +10045,A 23-year-old white female presents with complaint of allergies.,0 +4879,"Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",10 +992, Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,38 +5430,Emergency cesarean section.,24 +3978, Left endoscopic carpal tunnel release and endotracheal fasciotomy.,38 +8297,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +9779,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1027," Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",11 +5240,Patient with immune thrombocytopenia,35 +5832,"The client underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the client had improved.",10 +1507," Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +5453,"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",29 +10413,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +7633,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6887,"Normal physical exam template. Well developed, well nourished, in no acute distress.",25 +8140,Patient today with ongoing issues with diabetic control.,13 +8056,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +12348,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +8623,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +10851,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +1761, The patient has NG tube in place for decompression.,15 +12227,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +7396,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12164,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10067,Occupational medicine consult with questions-answers.,18 +6003,The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal discomfort which has been persistent.,12 +2524," Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.",15 +1192, Full mouth dental rehabilitation in the operating room under general anesthesia.,38 +2159, 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.,14 +4278,Occupational medicine consult with questions-answers and records review.,18 +2303, Right heart catheterization. Refractory CHF to maximum medical therapy.,3 +2535," Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ",23 +137," A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.",5 +3022," An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.",5 +11963,Work restrictions and disability evaluation,18 +7375,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +1560," Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",27 +2662, A 75-year-old female comes in with concerns of having a stroke.,35 +3911, A 34-year old female with no fetal heart motion noted on office scan.,33 +6786,Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib ache related to a herniated nucleus pulposus at T8-T9.,23 +2732," Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye",26 +12177,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1841, Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones.,14 +679," Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.",27 +1393, Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. ,10 +4067,HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 +5943,"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +10716,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2378, Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,38 +12326,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12614,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +1097," Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.",3 +5872,A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.,16 +7469,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +3451," Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan.",3 +6420,An example normal physical exam,25 +7217,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5918,Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,16 +11284,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +4047,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 +2057, Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. ,16 +12487,Dietary consultation for carbohydrate counting for type I diabetes.,9 +6167,"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.",6 +6856,"Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",11 +5971,Ophthalmology followup visit note.,26 +5321,"A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",29 +7511,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5132,"Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",39 +2984," Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.",38 +340, Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,14 +9387,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11715,A sample note on Rheumatoid Arthritis,34 +3666, Right middle ear exploration with a Goldenberg TORP reconstruction.,11 +11628,Dietary consultation for gestational diabetes.,9 +4248,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,16 +2917, Left Iliopsoas hematoma. Gait difficulty.,22 +10171,Consultation for left foot pain.,4 +3685, Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,5 +7166,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +8831,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +8643,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +7754,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +9870,Dietary consultation for diabetes during pregnancy.,9 +7255,Autopsy of a white female who died of acute combined drug intoxication.,1 +8642,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10477,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +7827,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +993," Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 +549, Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,38 +1043, Tube Shunt - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.,38 +2232," Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.",3 +396," Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain. ",30 +3163, Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,38 +10585,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +11307,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +2194," 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.",6 +7958,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +10331,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +3030," 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.",35 +148," Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",15 +684," The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.",3 +11534,Work restrictions and disability evaluation,4 +3748, Frontal and lateral views of the hip and pelvis.,33 +11655,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10624,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9702,A sample note on Rheumatoid Arthritis,34 +5421,"A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 +8583,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +5187,"Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",24 +1568, A 5-month-old boy brought by his parents because of 2 days of cough. ,29 +9732,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3086, Normal vasectomy,38 +11124,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8652,Follow up update on case with left carotid angioplasty and stent placement.,20 +573," Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",38 +5728,Common CT Neck template.,11 +4497,Right distal ureteral calculus. The case had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.,39 +7063,"Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.",31 +5807,Bilateral sacroiliac joint injections,28 +10256,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7696,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +9879,Mother states he has been wheezing and coughing.,0 +5608,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +6125,Trabeculectomy with mitomycin C - Sample/Template.,26 +4614,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",10 +8985,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +3325," The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",16 +4422,Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 +6218,Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique.,28 +7184,Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 +6785,MRI right ankle.,31 +9634,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2697, Complete eye examination - Normal eye and vision exam.,26 +9946,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +7677,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +1511, A 37 year-old female with twin pregnancy with threatened premature labor.,24 +9679,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10099,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +11354,Consultation for left foot pain.,4 +186," Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",38 +11606,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7340,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3539, CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.,22 +4370,Most commonly used phrases in physical exam.,25 +370, Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site,38 +2096," School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",35 +9041,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +11853,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +9707,A sample note on Rheumatoid Arthritis,34 +9512,Autopsy of a white female who died of acute combined drug intoxication.,1 +2437," Visually significant nuclear sclerotic cataract, right eye. Phacoemulsification with posterior chamber intraocular lens implantation, right eye.",38 +4823,A white female presents for exam and Pap.,24 +2559," Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",32 +4306,"Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.",15 +7072,"Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",29 +11312,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +11633,Dietary consultation for gestational diabetes.,9 +2481," Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 +2796, Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor. ,23 +7327,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12517,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +8663,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +2520, Common description of colonoscopy,38 +7671,"Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +5299,Fifth disease with sinusitis,35 +6293,"Adenotonsillectomy, primary, client under age 12.",11 +4080,"Pressure decubitus, right hip",15 +2371," Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.",3 +1248, Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,38 +6690,"A 7-year-old white male started to complain of discomfort in his fingers, elbows, and neck. This patient may have had reactive arthritis.",29 +2875," She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.",35 +10312,Patient today with ongoing issues with diabetic control.,13 +2499, Colonoscopy to evaluate prior history of neoplastic polyps.,14 +3864," HCT: SAH, Contusion, Skull fracture",33 +8789,Is it BNP or BMP?,19 +8041,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +7730,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7009,Blepharoplasty procedure,26 +11247,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9247,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1673, 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.,38 +9310,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +8152,Consultation for wrist pain.,4 +11243,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +4596,"A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.",10 +456," Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",5 +8921,"Specimen labeled ""sesamoid bone left foot"".",19 +11589,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +9074,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +3796," Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.",28 +1731," Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.",3 +9517,Autopsy of a white female who died of acute combined drug intoxication.,1 +144," Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5042,Psychosocial Evaluation of client before kidney transplant.,32 +1765, Sleep study - patient with symptoms of obstructive sleep apnea with snoring.,36 +4771,The client states that he feels sick and weak.,35 +5672,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +11000,A 23-year-old white female presents with complaint of allergies.,0 +5067,"Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",35 +5014,Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 +12017,Consultation for left foot pain.,4 +6264,Patient presents to the emergency department (ED) with rectal bleeding and discomfort on defecation.,12 +7034,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +11790,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9464,Mother states he has been wheezing and coughing.,0 +11215,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +4866,"Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 +2974, Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.,14 +2185," Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.",38 +4003,This is a middle-aged female with two month history of low back ache and leg pain.,22 +994," Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",21 +11216,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +242," Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. ",16 +3498, Small office note on premature retina and vitreous.,26 +2219," Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +1775," Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.",38 +5899,"The case is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",10 +7109,Autopsy - Asphyxia due to ligature strangulation.,1 +10178,Mother states he has been wheezing and coughing.,0 +10056,Work restrictions and disability evaluation,18 +973," Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",21 +12535,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3262," Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. ",15 +7325,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10731,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +3973, Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,32 +5285,"Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the client has had multiple catheterizations recently and has history of peripheral vascular disease.",39 +8678,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +6268,Pain management sample progress note.,28 +2130, Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,5 +4594,"A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.",10 +7665,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +7669,Work restrictions and disability evaluation,4 +8959,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +2928," Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",16 +9303,Autopsy - Asphyxia due to ligature strangulation.,1 +6248,Autopsy of a white female who died of acute combined drug intoxication.,1 +7857,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +3582, A 66-year-old female with knee osteoarthrosis who failed conservative management.,10 +4327,"Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 +4508,"Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 +4798,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +10581,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3716, Patient with a past medical history of hypertension for 15 years.,15 +9159,Occupational medicine consult with questions-answers and records review.,18 +4553,A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 +11485,Patient scheduled for laparoscopic gastric bypass.,2 +727," Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.",38 +11835,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2117," Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",21 +11932,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +4331,"Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",10 +7821,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +6507,"Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.",23 +2608, Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.,3 +10770,Autopsy - Homicide - Blunt force cranial trauma,1 +9674,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5643,"Re-excision of squamous cell carcinoma site, right hand.",16 +7039,"Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 +8440,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +4396,Brain CT and MRI - suprasellar mass (pituitary adenoma),33 +3815, Common description of EGD,14 +4971,Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 +5805,"Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",25 +7951,"Specimen labeled ""sesamoid bone left foot"".",19 +2985, Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,38 +9833,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6855,"Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",11 +3425," Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.",24 +7553,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9124,Consult for laparoscopic gastric bypass.,2 +7234,"Specimen labeled ""sesamoid bone left foot"".",19 +8465,Occupational medicine consult with questions-answers and records review.,18 +5795,Mother states he has been wheezing and coughing.,0 +11769,Cause of death - Anoxic Encephalopathy,1 +10264,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +9561,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +6395,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +8588,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +3882," Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ",5 +10530,Occupational medicine consult with questions-answers and records review.,18 +1842, Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.,24 +11190,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +10706,Dietary consultation for diabetes during pregnancy.,9 +8821,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +4081,"Pressure decubitus, right hip",15 +3519, Symptomatic thyroid goiter. Total thyroidectomy.,15 +12469,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +1847, Intermittent rectal bleeding with abdominal pain.,38 +3292," Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.",35 +7610,A sample note on Rheumatoid Arthritis,34 +2807, Common description of EGD.,14 +7673,"Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +2302, Status post cadaveric kidney transplant with stable function.,21 +6964,"Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +10820,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8347,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 +4686,AP abdomen and ultrasound of kidney.,21 +5525,"Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",29 +7224,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11344,"Specimen labeled ""sesamoid bone left foot"".",19 +2987, Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. ,10 +8117,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +8150,Consultation for wrist pain.,4 +2800," A 44-year-old, 250-pound male presents with extreme pain in his left heel.",35 +4979,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +12191,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8049,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +4010,Followup of moderate-to-severe sleep apnea. The client returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,15 +11257,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +3297, The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +11404,Preop evaluation regarding gastric bypass surgery.,2 +6798,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",31 +5172,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 +7886,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +10153,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +1837, Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.,3 +9654,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +426, Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,38 +946, A 3-year-old abrupt onset of cough and increased work of breathing.,29 +5709,"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.",23 +10328,Evaluation for chronic ache program,4 +10110,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +4934,"Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",39 +9526,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1439," Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..",15 +8528,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +6212,CT Abdomen & Pelvis W&WO Contrast,21 +10378,Patient scheduled for laparoscopic gastric bypass.,2 +4843,Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,24 +5970,Ophthalmology followup visit note.,26 +43, Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 +1047," Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 +3934," A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ",5 +7567,A 23-year-old white female presents with complaint of allergies.,0 +9721,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5137,A 23-year-old white female presents with complaint of allergies.,35 +9799,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7180,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +2701, This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +5298,Fifth disease with sinusitis,35 +3774, Discharge summary of a patient with a BRCA-2 mutation.,16 +9966,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +9135,Autopsy of a white female who died of acute combined drug intoxication.,1 +1776, Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal.,3 +1126, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,3 +6882,Psychological Testing for ADHD,32 +1170," Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye.",26 +8206,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +6471,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +10295,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +5240,Patient with immune thrombocytopenia,35 +6984,Patient with right ankle pain.,31 +2343," She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.",28 +3007, Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery,3 +799, The patient with atypical type right arm discomfort and neck discomfort.,38 +3337," Multiple contusions and abdominal pain, status post motor vehicle collision. ",15 +10735,"Specimen labeled ""sesamoid bone left foot"".",19 +5955,"Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +7566,A 23-year-old white female presents with complaint of allergies.,0 +1111, MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,22 +11042,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +528," 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.",35 +1921," Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.",38 +8464,Occupational medicine consult with questions-answers and records review.,18 +4134,"Patient with hypertension, dementia, and depression.",15 +5023,"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.",24 +1613, Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.,27 +10866,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10449,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent clinical evaluation.,18 +4113,"This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.",39 +3031, CCTA with cardiac function and calcium scoring.,33 +3192, Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.,39 +9156,Occupational medicine consult with questions-answers and records review.,18 +6581,"Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 +10846,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +6641,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +11708,Autopsy - Homicide - Blunt force cranial trauma,1 +880, Patient is here to discuss possible open lung biopsy.,35 +5416,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 +11554,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9841,A 23-year-old white female presents with complaint of allergies.,0 +9748,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3860," Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.",35 +1518, An example/template for a routine normal male physical exam.,5 +8411,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8621,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +11335,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +5402,An example of a physical exam,25 +4393,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",16 +10659,Work restrictions and disability evaluation,18 +10260,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +11687,Mother states he has been wheezing and coughing.,0 +4976,"A white female who presents for complete physical, Pap and breast exam.",24 +11625,Dietary consultation for gestational diabetes.,9 +11992,Dietary consultation for diabetes during pregnancy.,9 +1435, Normal vasectomy,39 +10125,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +11190,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +5165,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +4099,Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +10971,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9816,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +9775,Patient presents for care of suspected rheumatoid arthritis.,34 +5730,"Right hand laceration x3, repaired.",25 +6676,Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 +6432,Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,11 +10092,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +4566,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent determination of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +11680,"Specimen labeled ""sesamoid bone left foot"".",19 +1176, Epigastric herniorrhaphy. Epigastric hernia.,38 +256," Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",23 +3754, Left temporal craniotomy and removal of brain tumor.,38 +2107, Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,27 +68," The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",12 +1023," Right shoulder impingement syndrome, right suprascapular neuropathy.",5 +3395, Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,23 +3734," Sample normal ear, nose, mouth, and throat exam.",25 +3274, Bilateral lumbar sympathetic block. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. ,28 +7829,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +5907,"Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",21 +4445,Followup circumcision. The client had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 +12014,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +989, Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,38 +5435,"Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",28 +3901, Qualified medical evaluation report of a patient with back pain.,4 +5344,Occupational medicine consult with questions-answers and records review.,18 +2940," Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue, secondary closure of wound, and VAC insertion.",38 +6644,"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +8009,A sample note on Rheumatoid Arthritis,34 +8980,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +4274,"Management of end-stage renal disease (ESRD), the case on chronic hemodialysis, being admitted for chest pain.",21 +5720,Transnasal transsphenoidal approach in resection of pituitary tumor. The client is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 +9158,Occupational medicine consult with questions-answers and records review.,18 +274, Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,5 +47, Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +10360,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +2413, Aftercare of multiple trauma from an motor vehicle accident.,15 +1676," Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",22 +1192, Full mouth dental rehabilitation in the operating room under general anesthesia.,38 +7724,Most commonly used phrases in physical exam.,25 +1178, Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,38 +8818,Occupational medicine consult with questions-answers and records review.,18 +2155," Primary cesarean section by low-transverse incision. Term pregnancy, nonreassuring fetal heart tracing.",24 +698," Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",39 +6489,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +7362,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2497," Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.",27 +3668, Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.,38 +2427," Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",5 +12127,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +12548,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1634," Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",38 +6409,13 years old complaining about severe ear discomfort - Chronic otitis media.,29 +9209,Evaluation for chronic ache program,4 +9028,MRI report Cervical Spine (Chiropractic Specific),4 +3589, Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,3 +1565, Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.,39 +2332," Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.",38 +10829,Autopsy of a white female who died of acute combined drug intoxication.,1 +835, Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.,27 +12458,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +9961,Chiropractic IME with answers to questions from Insurance Company.,20 +3684, Neurologic consultation and follow-up.,22 +7631,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4363,Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 +11501,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3724," Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",38 +6345,"Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The client 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.",26 +12196,Dietary consultation for gestational diabetes.,9 +2488," Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.",3 +9007,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +1183, Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.,38 +8646,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +12242,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7206,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5309,Is it BNP or BMP?,19 +6298,Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 +5786,"Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 +1277," Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.",38 +8522,Chiropractic IME with answers to questions from Insurance Company.,20 +1831," Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. ",38 +1557, Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,5 +3797, MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,22 +5598,"Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.",23 +6868,"Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",11 +8291,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +8692,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +9985,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6113,A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 +9387,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1703, Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.,39 +4233,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +656, Hardware removal in the left elbow.,38 +11500,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +7873,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +12168,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +5749,One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 +7037,Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +33, Primary low-transverse cesarean section.,24 +6487,The patient continues to suffer from ongoing neck and lower back ache with no recent radicular complaints.,25 +12128,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4677,"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 +9765,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7795,Chiropractic IME with answers to questions from Insurance Company.,4 +11616,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2695," Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.",21 +6178,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +6697,"Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",11 +62," Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",35 +9987,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10168,Chiropractic IME with answers to questions from Insurance Company.,18 +4428,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,33 +10964,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3623," Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.",5 +2573, A well-child check with concern of some spitting up quite a bit.,5 +1302," Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +6440,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,29 +3756," Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.",15 +2089," Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",38 +11943,Chiropractic IME with answers to questions from Insurance Company.,4 +653, Cystoscopy & Visual urethrotomy procedure,38 +7419,Dietary consultation for diabetes during pregnancy.,9 +9861,Dietary consultation for gestational diabetes.,9 +2971, Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.,38 +9142,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +2309," Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",5 +2242," New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.",27 +6184,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +9818,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4942,"Counting calorie points, exercising pretty regularly, seems to be doing well",35 +11207,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +4563,Routine colorectal cancer screening. He occasionally gets some loose stools.,16 +7254,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7001,"The case is 14 months old, comes in with a chief complaint of difficulty breathing.",12 +6320,Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,26 +3542, Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,15 +3211," Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. +",38 +12049,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +11581,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +366, Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,38 +8857,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +546, Coronary Artery CTA with Calcium Scoring and Cardiac Function,33 +12270,Autopsy of a white female who died of acute combined drug intoxication.,1 +4714,"Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",35 +547, The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,32 +8175,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +689, Bronchoscopy for hypoxia and increasing pulmonary secretions,3 +8684,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +3890," The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.",5 +2490, A 10 years of age carries a diagnosis of cystic fibrosis,5 +1206," Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.",3 +8048,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +11016,Is it BNP or BMP?,19 +6021,Costochondral Cartilage Injection,28 +9109,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12297,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +615, Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,24 +4375,"Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",22 +5536,Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,23 +3982, Sports physical with normal growth and development.,5 +1327, Arterial imaging of bilateral lower extremities. ,3 +12591,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9939,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +6720,Left temporal craniotomy and removal of brain tumor.,23 +9181,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +3182, 13 years old complaining about severe ear pain - Chronic otitis media.,11 +1538," The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.",38 +6637,"Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",21 +11651,Dietary consultation for diabetes during pregnancy.,9 +11759,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +9802,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5703,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +10501,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +12317,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3410," Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",27 +1599," A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",35 +8324,Bilateral reduction mammoplasty for bilateral macromastia,6 +5880,Bilateral temporal artery biopsy. Rule out temporal arteritis.,23 +1438," Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.",24 +1865, A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.,35 +3335, Patient presents with gross hematuria that started this morning.,5 +1499," Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 +3439, Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. ,35 +10448,Back injury with RLE radicular symptoms. The case is a 52-year-old male who is here for independent medical evaluation.,18 +1555," Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",27 +5195,Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,24 +6645,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +9199,Consultation for wrist pain.,4 +11054,A sample note on Rheumatoid Arthritis,34 +78, Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,38 +5154,a pleasant 62-year-old male with cerebral palsy,10 +5521,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +2197," A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.",10 +9728,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1917, Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.,38 +3640, MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,22 +1055," Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ",5 +2665," This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",15 +11046,Autopsy - Homicide - Blunt force cranial trauma,1 +6627,Excisional biopsy of right cervical lymph node.,16 +10155,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +796," Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.",14 +5037,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The case is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +4700,A 34-year old female with no fetal heart motion noted on office scan.,24 +9061,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +11893,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3216, Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe. ,28 +9342,Patient presents for care of suspected rheumatoid arthritis.,34 +10920,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +5153,"Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",12 +11946,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +12604,Autopsy - Homicide - Blunt force cranial trauma,1 +3791, Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +6454,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +5848,"Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 +5809,Bilateral sacroiliac joint injections,28 +10897,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +9191,Consult for laparoscopic gastric bypass.,2 +9673,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2827, Noncontrast CT abdomen and pelvis per renal stone protocol.,21 +3511, Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,38 +4758,Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,28 +4793,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +11855,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +2544, Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. ,16 +10196,The client underwent an overnight polysomnogram.,36 +1902, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,38 +10796,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +8826,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +8578,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2788," Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.",38 +10291,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +376," Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 +9603,Patient presents for therapy of suspected rheumatoid arthritis.,34 +12428,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +8338,Autopsy - Asphyxia due to ligature strangulation.,1 +7505,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +10699,Dietary consultation for diabetes during pregnancy.,9 +12065,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +10072,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +7822,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +4104,"Right shoulder impingement syndrome, right suprascapular neuropathy.",22 +9081,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5722,Transnasal transsphenoidal approach in resection of pituitary tumor. The client is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 +12141,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6517,Complete eye examination - Normal eye and vision exam.,26 +2591," Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. ",38 +11785,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +485," Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.",38 +5502,Circumcision in an older person,39 +7799,Incision and drainage (I&D) of buttock abscess.,8 +4768,Polycythemia rubra vera. The client is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 +4711,"Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.",10 +5263,"Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",11 +4749,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +4260,"The case is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.",32 +5210,Occupational medicine consult with questions-answers.,18 +7802,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8970,Mother states he has been wheezing and coughing.,0 +8082,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +4075,Patient in ER with upper respiratory infection,15 +3419," Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.",38 +9916,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4653,She was admitted following an overdose of citalopram and warfarin. The client has had increasing depression and has been under stress as a result of dissolution of her second marriage.,32 +5068,"Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",35 +2099," Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.",5 +1911, Lower lid blepharoplasty.,26 +2610," Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.",24 +3020," Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",38 +9052,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +9195,Consultation for wrist pain.,4 +1606," Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).",38 +3693, Noncontrast CT abdomen and pelvis per renal stone protocol.,33 +3857," The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.",37 +12617,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +11597,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +849, Ophthalmology followup visit note.,26 +4510,"Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 +1557, Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,5 +5439,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +11364,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8259,Acne with folliculitis.,8 +9986,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +9426,Is it BNP or BMP?,19 +11183,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +10247,Preop evaluation regarding gastric bypass surgery.,2 +2563, Whole body PET scanning.,33 +8574,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +41, Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips.,38 +9930,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +5366,Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,24 +8536,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1445," Left orchiopexy. Ectopic left testis. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.",39 +9461,Mother states he has been wheezing and coughing.,0 +6925,"Lower quadrant discomfort with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 +6479,Evaluation for chronic ache program,4 +10993,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10422,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +2991," The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",29 +6948,Caudal epidural steroid injection,28 +11786,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +1827," Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.",14 +5392,"Fever, otitis media, and possible sepsis.",29 +4527,"Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 +4719,This case has reoccurring ingrown infected toenails.,31 +1931," 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.",5 +7662,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6237,"A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.",10 +10704,Dietary consultation for diabetes during pregnancy.,9 +565," Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",27 +8982,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9409,A 23-year-old white female presents with complaint of allergies.,0 +9525,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7247,A sample note on Rheumatoid Arthritis,34 +10208,A 21-channel digital electroencephalogram was performed on a case in the awake state.,36 +159, A 65-year-old man with chronic prostatitis returns for recheck.,35 +11929,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2316," Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",38 +11552,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3512, Bilateral myringotomy tubes and adenoidectomy.,38 +9059,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +1743, Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe.,3 +2496," This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ",5 +4211,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +12100,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8154,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +11244,Chiropractic IME with answers to questions from Insurance Company.,4 +5148,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8996,Autopsy - Homicide - Blunt force cranial trauma,1 +8812,Occupational medicine consult with questions-answers and records review.,18 +2517, Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia.,39 +10043,"The skin biopsy was performed on the right ankle and right thigh. The case was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +4400,The patient is admitted with a determination of acute on chronic renal insufficiency.,21 +9420,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7507,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +5190,"Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The client works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.",31 +12434,Mother states he has been wheezing and coughing.,0 +3655, 2-D Echocardiogram,3 +3956, Tracheotomy for patient with respiratory failure.,38 +387, Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,38 +3441," Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.",23 +8095,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +7119,The case presents for evaluation at the request of his primary physician for treatment for dystrophic nails.,31 +10878,Cause of death - Anoxic Encephalopathy,1 +11710,Autopsy - Homicide - Blunt force cranial trauma,1 +6299,Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 +390," Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.",15 +3996," Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +545, Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.,27 +12298,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9004,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +11024,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +279, 4-day-old with hyperbilirubinemia and heart murmur.,12 +6141,"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",21 +6602,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The client fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +2980," Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",15 +8832,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +1297," Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",5 +635, Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. ,27 +2772," Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",22 +1701," Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",35 +7176,"Intercostal block from fourth to tenth intercostal spaces, left. Chest discomfort secondary to fractured ribs, unmanageable with narcotics.",28 +10787,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +2211," Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.",38 +11087,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2147," Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",15 +10986,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4190,Patient with intermittent episodes of severe nausea and abdominal pain.,15 +1532," Sterilization candidate. Cervical dilatation and laparoscopic bilateral partial salpingectomy. A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.",38 +11924,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2803, Patient with a 1-year history of progressive anterograde amnesia,22 +12286,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6220,Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique.,28 +10733,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +338, Evaluation for chronic pain program,27 +12131,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4374,"Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",22 +5667,"Specimen labeled ""sesamoid bone left foot"".",19 +6554,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +11839,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3976, Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.,27 +4849,Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.,24 +1596, Common CT C-Spine template,27 +978," Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",26 +1893, Bilateral Myringotomy with placement of PE tubes,38 +5779,Aftercare of multiple trauma from an motor vehicle accident.,10 +3449, Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.,14 +11934,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +10688,Is it BNP or BMP?,19 +2313, Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,38 +2422, Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,38 +1898, CT of the abdomen and pelvis without contrast.,14 +5074,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +11735,Autopsy of a white female who died of acute combined drug intoxication.,1 +10406,Dietary consultation for carbohydrate counting for type I diabetes.,9 +12589,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6980,Itchy red rash on feet - Tinea Pedis,31 +593, Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,38 +594, A white female presents for exam and Pap.,24 +10754,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +3818, Stroke in distribution of recurrent artery of Huebner (left),22 +3248, 2-D M-Mode. Doppler. ,3 +8266,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 +6761,"Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",31 +8566,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +12155,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4534,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",35 +5308,Is it BNP or BMP?,19 +4990,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +7206,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5225,"Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",24 +12265,Autopsy of a white female who died of acute combined drug intoxication.,1 +10592,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2412, Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. ,12 +11141,A sample note on Rheumatoid Arthritis,34 +3686, 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. ,16 +4342,"Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.",14 +168, Common description of EGD,38 +8885,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +3712, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,3 +8249,"Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,",8 +216, Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,23 +3982, Sports physical with normal growth and development.,5 +5019,Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.,35 +1702, Right upper lung lobectomy. Mediastinal lymph node dissection,38 +7202,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3699," Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. + ",38 +12281,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6199,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +9668,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6170,"A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.",10 +7226,Is it BNP or BMP?,19 +8871,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10925,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9622,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10987,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8934,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +9483,Autopsy - Homicide - Blunt force cranial trauma,1 +1934, 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias.,38 +9620,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +232," Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +890," For evaluation of left-sided chest pain, 5 days post abdominal surgery.",5 +10000,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +4489,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +9829,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +8058,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +415, Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.,38 +11700,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +1360, Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 +5867,Template for History and Physical for a newborn.,25 +101," Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",14 +8409,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4145,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",10 +11349,Chiropractic IME with answers to questions from Insurance Company.,18 +2018, Occupational medicine consult with questions-answers.,5 +6419,"Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",23 +12103,Autopsy - Asphyxia due to ligature strangulation.,1 +10047,A 23-year-old white female presents with complaint of allergies.,0 +7812,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +1355, Central line insertion. Empyema thoracis and need for intravenous antibiotics.,3 +442," New diagnosis of non-small cell lung cancer stage IV metastatic disease. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.",5 +9918,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4488,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +3928," The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +11586,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4752,"Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder ache and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",35 +2936," Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.",38 +6005,Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +5167,"Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",39 +8914,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +8289,Dietary consultation for carbohydrate counting for type I diabetes.,9 +11873,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5934,A sample note on Rheumatoid Arthritis,34 +9349,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +928, Patient with back and hip pain.,5 +6316,Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 +5935,A sample note on Rheumatoid Arthritis,34 +10277,Autopsy of a white female who died of acute combined drug intoxication.,1 +4250,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,16 +355, Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.,38 +10222,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +6142,"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",21 +11916,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +636," Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.",3 +6920,"Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming determination of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.",12 +8728,Work restrictions and disability evaluation,18 +11479,Qualified medical evaluation report of a case with back pain.,18 +8273,Chronic snoring in children,36 +1566, MRI for Arnold Chiari II with syrinx,22 +2948," Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",16 +12305,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11711,A sample note on Rheumatoid Arthritis,34 +1690, Aftercare of multiple trauma from an motor vehicle accident.,10 +11848,A sample note on Rheumatoid Arthritis,34 +11100,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8233,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +3992," Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",16 +5037,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The case is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +2396," Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +4925,"Follow up consultation, second opinion, foreskin.",39 +11518,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +1637," Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",35 +10736,"Specimen labeled ""sesamoid bone left foot"".",19 +5813,Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 +6034,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +3278," Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.",3 +6306,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +12307,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8570,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +8061,Preop evaluation regarding gastric bypass surgery.,2 +3647, Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,3 +2541, 13 years old complaining about severe ear pain - Chronic otitis media.,29 +4283,Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 +4889,Transforaminal epidural steroid block with fluoroscopy.,28 +9096,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +10463,"Records review. The client developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +509, A sample note on Conjunctivitis (Pink Eye).,26 +315," Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.",38 +8890,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +9616,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6543,"Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.",11 +10868,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11853,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +10078,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +3284," Closure of bladder laceration, during cesarean section.",38 +8978,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +7245,Autopsy - Homicide - Blunt force cranial trauma,1 +2127," The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",22 +9091,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +6034,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +9527,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11925,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +11721,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +5467,"C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",23 +2634, Chronic cholecystitis without cholelithiasis.,14 +11588,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11543,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11136,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5100,A 23-year-old white female presents with complaint of allergies.,0 +8653,Follow up update on case with left carotid angioplasty and stent placement.,20 +11578,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7632,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7255,Autopsy of a white female who died of acute combined drug intoxication.,1 +10364,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +9523,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +10366,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +9863,Dietary consultation for gestational diabetes.,9 +12391,Chiropractic IME with answers to questions from Insurance Company.,4 +2801," 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. ",5 +5900,"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",16 +2783, Esophagogastroduodenoscopy with biopsy.,14 +2462," Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.",38 +5622,A simple note on Acne Vulgaris.,8 +6325,Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement.,12 +17," Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. ",23 +10634,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +2926," Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",11 +8460,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +8579,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +1608," Congestion, tactile temperature.",5 +6164,Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 +8153,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +10788,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +1587, Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,38 +714, Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,27 +9574,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +98, Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.,10 +5466,"C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",23 +2483," Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",15 +2857, Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis. ,27 +5862,Left hip fracture. The case is a 53-year-old female with probable pathological fracture of the left proximal femur.,12 +9602,Patient presents for therapy of suspected rheumatoid arthritis.,34 +3535," Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.",35 +4135,"Patient with hypertension, dementia, and depression.",15 +450, A 47-year-old female with a posttraumatic AV in the right femoral head.,10 +4785,The client was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,32 +6974,"Female with intermittent rectal bleeding, not associated with any weight loss. The client is chronically constipated.",20 +9827,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +5119,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +12214,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +276," Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 +3733, Examination due to blood-borne pathogen exposure.,15 +6215,"The case is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 +2209, A white female with a history of fevers.,15 +7751,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +7761,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +2004," Austin bunionectomy with internal screw fixation, first metatarsal, left foot.",38 +2877," Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.",24 +3981, Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,3 +6119,"Austin/akin bunionectomy, right foot. Bunion, right foot. The client states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",31 +4454,"Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past clinical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.",22 +3061, Psychiatric consultation of patient with lethargy.,5 +539," A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",30 +2117," Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",21 +5723,Adenoidectomy procedure,11 +1310, Patient referred for narrow angles and possible associated glaucoma.,20 +8660,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +9276,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +11288,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +8441,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +4084,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2860, Reduction of paraphimosis.,39 +2940," Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue, secondary closure of wound, and VAC insertion.",38 +8509,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +7702,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +5246,Death summary of client with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,10 +10675,Dietary consultation for gestational diabetes.,9 +1314, Right nodular malignant mesothelioma.,38 +10836,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +12471,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +3057, L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,28 +5941,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +8667,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +3812, Bronchoscopy. Atelectasis and mucous plugging.,38 +11523,Qualified clinical evaluation report of a patient with back pain.,4 +10222,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +5482,"Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",12 +2105, Esophagogastroduodenoscopy with biopsy.,38 +706, Left retrosigmoid craniotomy and excision of acoustic neuroma.,23 +908, Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,23 +5075,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +11150,A sample note on Rheumatoid Arthritis,34 +10349,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The client fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +10652,A 23-year-old white female presents with complaint of allergies.,0 +3564," Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",38 +10934,Autopsy - Asphyxia due to ligature strangulation.,1 +10635,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +1680, Diagnostic fiberoptic bronchoscopy.,38 +8185,Cause of death - Anoxic Encephalopathy,1 +1546," Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ",15 +488," Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",24 +6319,Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,26 +7285,Patient presents for therapy of suspected rheumatoid arthritis.,34 +801, Thoracentesis. Left pleural effusion. Left hemothorax.,38 +12508,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +843, 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.,3 +7642,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11507,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3634, Right radical nephrectomy and assisted laparoscopic approach.,38 +5949,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +2596, Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +3550," Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.",22 +2271," The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.",15 +8672,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +963," Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",35 +701," Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.",38 +3085, Appendicitis. Laparoscopic appendectomy. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.,14 +4705,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +8751,Occupational medicine consult with questions-answers.,18 +10827,Autopsy of a white female who died of acute combined drug intoxication.,1 +658," Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. ",22 +10641,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +5034,Psychiatric Consultation of client with anxiety.,32 +7794,Chiropractic IME with answers to questions from Insurance Company.,4 +7554,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8966,Mother states he has been wheezing and coughing.,0 +5510,Discharge summary of a case with depression and high risk behavior.,10 +9974,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +1867, Preop evaluation regarding gastric bypass surgery.,35 +8330,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12248,Autopsy - Homicide - Blunt force cranial trauma,1 +6226,Consult for laparoscopic gastric bypass.,2 +11179,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +9394,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8894,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +5472,"The client with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",26 +10264,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +3805," Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.",35 +7678,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +3986, Normal cataract surgery. ,26 +12199,Dietary consultation for gestational diabetes.,9 +875," Patient with multiple problems, main one is chest pain at night.",5 +9018,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +3220, Ophthalmology followup visit note.,35 +11993,Dietary consultation for diabetes during pregnancy.,9 +3624, A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,16 +11035,Mother states he has been wheezing and coughing.,0 +11958,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +1174," Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. ",15 +9214,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +756, Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.,3 +10401,Chronic snoring in children,36 +5332,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +2904," Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",3 +1125, CT Brain: Subarachnoid hemorrhage.,33 +10736,"Specimen labeled ""sesamoid bone left foot"".",19 +1439," Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..",15 +10075,Dietary consultation for gestational diabetes.,9 +4723,A sample note on Conjunctivitis (Pink Eye).,26 +11139,A sample note on Rheumatoid Arthritis,34 +5977,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",26 +7147,"A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",32 +8626,Chiropractic IME with answers to questions from Insurance Company.,4 +5564,"Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +447," Patient with atrial fibrillation with slow ventricular response, partially due to medications.",5 +4607,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +5498,"Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 +10165,Blepharoplasty procedure,6 +10462,Patient presents for therapy of suspected rheumatoid arthritis.,34 +8632,Chiropractic IME with answers to questions from Insurance Company.,4 +11749,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +7194,Well-child check and school physical.,29 +8087,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +176, Patient with morbid obesity.,5 +2039, Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,38 +1665," Bassini inguinal herniorrhaphy. A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ",39 +10890,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11230,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6654,"Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",16 +1468, Return to work & Fit for duty evaluation.,15 +2626," Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.",38 +10604,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +1902, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,38 +10021,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +6398,Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +11315,Dietary consultation for diabetes during pregnancy.,9 +5387,"Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum.",24 +8412,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2143, Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.,35 +12571,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4156,Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,39 +9563,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +12124,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +495," Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.",27 +9089,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +11689,Mother states he has been wheezing and coughing.,0 +9979,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +8376,Patient presents for therapy of suspected rheumatoid arthritis.,34 +9544,Cause of death - Anoxic Encephalopathy,1 +4160,"A complex closure and debridement of wound. The client is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",23 +7512,Elevated cholesterol and is on medication to lower it.,9 +7172,"The case with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +9385,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +5634,"Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.",16 +3336, Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,29 +434, Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. ,38 +1100, MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,33 +7678,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +3307," Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",5 +7486,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +1301, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +2391, Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 +2621," 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.",38 +4011,Direct right inguinal hernia. Marlex repair of right inguinal hernia.,39 +12643,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1751," Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",5 +432, Decreased ability to perform daily living activity secondary to recent right hip surgery.,27 +2428, Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,15 +11527,Elevated cholesterol and is on medication to lower it.,9 +2110, A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,3 +6762,"Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",21 +4290,"Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 +4949,Follow up update on client with left carotid angioplasty and stent placement.,20 +5426,"Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to clinical therapy, severe anemia, and fibroid uterus.",10 +8239,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +6296,Nephrology office visit for followup of CKD.,21 +4539,Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,23 +6820,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +5519,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +8378,"Records review. The patient developed shooting discomfort about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +2572, Neurologic consultation was requested to evaluate her seizure medication and lethargy.,22 +5083,Right radical nephrectomy and assisted laparoscopic approach.,21 +6751,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 +313," Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 +6608,"Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",21 +9650,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7588,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +7107,Bender-Gestalt Neurological Battery and Beck testing.,32 +4761,An example/template for a routine normal male physical exam.,25 +2336, Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. ,35 +5039,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The case is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +1668, Upper endoscopy with removal of food impaction.,14 +999," Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.",38 +8838,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +9989,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +7889,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +8268,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +7820,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +1907, Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.,39 +4300,Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.,11 +3854, Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. ,5 +9446,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9145,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +2569, Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,29 +11517,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +2787," Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.",3 +505," Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",35 +2639," Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.",38 +458, Circumcision procedure in a baby,38 +12395,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7255,Autopsy of a white female who died of acute combined drug intoxication.,1 +7816,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +4899,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10843,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +11998,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +780," Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass.",38 +7358,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +2658," Missed abortion. Suction, dilation, and curettage.",38 +2161," Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",27 +5162,"Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",25 +12061,Autopsy of a white female who died of acute combined drug intoxication.,1 +6620,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",16 +2880," Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.",15 +10320,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +7960,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +9202,Consultation for wrist pain.,4 +771," Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.",38 +6860,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The client is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",29 +9271,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4336,Esophagogastroduodenoscopy performed in the emergency department.,14 +10001,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +8677,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +3500, Right foot series after a foot injury.,33 +10607,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +11962,A 23-year-old white female presents with complaint of allergies.,0 +9765,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4473,"Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.",24 +1713," Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.",38 +11365,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10061,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7080,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10927,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10970,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3707, The patient with a recent change in bowel function and hematochezia.,38 +6663,Belly button piercing for insertion of belly button ring.,6 +7721,Patient dropped a weight on the dorsal aspects of his feet.,31 +10337,Preoperative visit for weight management with laparoscopic gastric banding,2 +715, MRI left knee without contrast.,27 +10336,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +7864,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +1258," Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",27 +8278,Initial evaulation - neck and back pain.,4 +5170,"Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",35 +9035,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +12174,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1684," Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",14 +1153, The patient was running and twisted her right ankle - right ankle sprain.,5 +136," Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.",38 +1230, Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,27 +11280,Occupational medicine consult with questions-answers.,18 +11060,A sample note on Rheumatoid Arthritis,34 +12076,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4840,"Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",22 +9269,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +2968," Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",31 +5507,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +4071,Primary low-transverse cesarean section.,24 +2320, Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. Posterior leaflet abscess resection.,3 +2690, Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.,5 +10541,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +12115,Elevated cholesterol and is on medication to lower it.,9 +9520,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +8348,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +10940,Autopsy - Asphyxia due to ligature strangulation.,1 +8983,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +3126, Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias,3 +6957,Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with identification of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,29 +12232,Mother states he has been wheezing and coughing.,0 +5495,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +6822,"Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.",21 +5888,Pain and swelling in the right foot.,31 +11647,Dietary consultation for diabetes during pregnancy.,9 +11928,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +3275, Ruptured appendicitis.,14 +7046,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent determination of urinary tract infection on outpatient treatment with nitrofurantoin.,12 +11747,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +9256,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +12533,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7050,Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The case is a 78-year-old female with back pain referring into the left side.,28 +8261,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +7400,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +3344," He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ",29 +11331,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +6638,"Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.",21 +2166," CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.",22 +9735,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12052,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +768, Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,38 +12405,A 23-year-old white female presents with complaint of allergies.,0 +7398,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7214,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12464,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5877,Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 +1900," A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.",35 +9261,Dietary consultation for carbohydrate counting for type I diabetes.,9 +12502,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +9456,"Specimen labeled ""sesamoid bone left foot"".",19 +5884,Hispanic male case was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +9100,Preop evaluation regarding gastric bypass surgery.,2 +4027,"Laparoscopic tubal sterilization, tubal coagulation.",24 +179," Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. ",15 +8730,Evaluation for bariatric surgery.,2 +3156, CT of abdomen with and without contrast. CT-guided needle placement biopsy.,38 +3277," Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",23 +8374,Evaluation and recommendations regarding facial rhytids.,8 +4703,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +5287,"Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.",24 +2091," Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9206,Evaluation for chronic discomfort program,4 +2939, Transvaginal ultrasound to evaluate pelvic pain.,24 +7067,"Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The client was given discharge instructions on wound care.",12 +5804,"Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",25 +10093,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +4526,"Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 +3325," The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",16 +77," Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",11 +3810," A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.",15 +8808,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +9329,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3926," Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",38 +4997,"Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",21 +3161," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",38 +9633,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11925,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +12486,Dietary consultation for carbohydrate counting for type I diabetes.,9 +4383,Bilateral renal ultrasound.,33 +2212, Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 +12632,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10318,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +1004," Acute appendicitis, gangrenous. Appendectomy.",38 +7826,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +4229,Resting Myoview and adenosine Myoview SPECT,33 +3378," Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.",38 +5252,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",12 +7988,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 +5524,Patient referred for narrow angles and possible associated glaucoma.,20 +3060, The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. ,5 +4359,"Open reduction, nasal fracture with nasal septoplasty.",11 +4173,"Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",14 +2715, Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,31 +5597,"Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.",23 +45, Sample of Pulmonary Function Test,3 +11652,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4475,Left temporal craniotomy and removal of brain tumor.,22 +9738,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7232,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10493,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +8157,Evaluation for chronic ache program,4 +11496,Dietary consultation for carbohydrate counting for type I diabetes.,9 +6129,A 66-year-old client who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 +12323,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3121," The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",33 +8212,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +3102, Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,33 +1003," The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +11185,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +7621,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +3497," Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.",11 +11026,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +7556,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4944,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +7998,Autopsy - Homicide - Blunt force cranial trauma,1 +10919,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10242,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +9690,A sample note on Rheumatoid Arthritis,34 +10842,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +3267," 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.",23 +2127," The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. ",22 +7319,A sample note on Rheumatoid Arthritis,34 +998, Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +526," A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",30 +2643," Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +4249,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,16 +7839,A 23-year-old white female presents with complaint of allergies.,0 +5740,"The case comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.",32 +4395,Brain CT and MRI - suprasellar mass (pituitary adenoma),33 +1050," Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",10 +10709,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10870,Cause of death - Anoxic Encephalopathy,1 +8819,Occupational medicine consult with questions-answers and records review.,18 +1946, Injection of bilateral carpal tunnels,28 +11271,Work restrictions and disability evaluation,18 +9436,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9292,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3078," Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.",27 +1589, Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,5 +11012,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4151,LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,24 +9623,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11776,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11814,Patient presents for care of suspected rheumatoid arthritis.,34 +10503,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +12251,Autopsy - Homicide - Blunt force cranial trauma,1 +3264, MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.,33 +9237,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +3778," Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",33 +588, The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,14 +11851,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6362,Repair of ruptured globe involving posterior sclera - Sample/Template.,26 +10112,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +7725,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +9188,Consult for laparoscopic gastric bypass.,2 +346," He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.",3 +5688,"Left orchiectomy, scrotal exploration, right orchidopexy.",39 +6260,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +12543,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6368,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +111," This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.",5 +1785," Primary low transverse cervical cesarean section. Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.",24 +8565,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +2324, Psychiatric Consultation of patient with recurring depression.,5 +3897," Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",23 +2943," Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",38 +12354,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7035,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +7320,A sample note on Rheumatoid Arthritis,34 +879," A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",3 +2037, Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.,38 +3749," Counting calorie points, exercising pretty regularly, seems to be doing well",9 +1905," Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.",38 +5769,Blepharoplasty procedure,6 +7312,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3294, Routine colorectal cancer screening. He occasionally gets some loose stools. ,5 +12659,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8006,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +2266," Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.",38 +1290, Marked right hydronephrosis without hydruria. ,5 +3561," Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.",38 +5480,"Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",12 +10191,Autopsy - Homicide - Blunt force cranial trauma,1 +557," Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.",38 +1137, Difficulty with both distance vision and with fine print at near.,26 +1479," Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",31 +2315," The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.",22 +9498,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5817,Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,10 +432, Decreased ability to perform daily living activity secondary to recent right hip surgery.,27 +3670," A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ",22 +10109,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6144,"Normal physical exam template. Normocephalic. Negative lesions, negative masses.",25 +11343,"Specimen labeled ""sesamoid bone left foot"".",19 +1164, An example/template for a routine normal male physical exam.,5 +9691,A sample note on Rheumatoid Arthritis,34 +3977," Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.",24 +12063,Autopsy of a white female who died of acute combined drug intoxication.,1 +7348,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1850, Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,16 +3542, Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,15 +6259,Psychosocial evaluation of kidney donor. Questions - Answers,32 +4685,AP abdomen and ultrasound of kidney.,21 +481," Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",38 +5566,"Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +7385,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +3839, Endovascular Brachytherapy (EBT),33 +11674,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +5308,Is it BNP or BMP?,19 +288," Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus. ",10 +2034," Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. ",27 +2051, The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +2318, Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,12 +9843,A 23-year-old white female presents with complaint of allergies.,0 +5003,Vaginal discharge with a foul odor.,24 +1234," Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.",38 +460, Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. Adenocarcinoma of the prostate.,38 +11416,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +11033,Mother states he has been wheezing and coughing.,0 +3179," Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 +12267,Autopsy of a white female who died of acute combined drug intoxication.,1 +6022,Costochondral Cartilage Injection,28 +21," Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.",3 +12030,A sample note on Rheumatoid Arthritis,34 +9603,Patient presents for therapy of suspected rheumatoid arthritis.,34 +9540,Cause of death - Anoxic Encephalopathy,1 +676," Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +9573,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9914,Work restrictions and disability evaluation,4 +12446,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +11710,Autopsy - Homicide - Blunt force cranial trauma,1 +10947,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8694,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +5226,"Head injury, anxiety, and hypertensive emergency.",29 +2112, Cadaveric renal transplant to right pelvis - endstage renal disease.,38 +4418,A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the case is 53 months out from transplant.,35 +7277,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12070,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +1859," Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",15 +8019,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid care to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +10261,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +609," Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",22 +5565,"Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +11408,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +10702,Dietary consultation for diabetes during pregnancy.,9 +5438,Psychiatric consultation for management of ache medications.,32 +2585, MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,33 +81, Normal upper GI endoscopy.,14 +10333,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +7105,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +5048,Cardiology office visit sample note.,25 +12273,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +9211,Evaluation for chronic ache program,4 +10773,A sample note on Rheumatoid Arthritis,34 +9889,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +3236, The patient brought in by EMS with a complaint of a decreased level of consciousness.,5 +3895, MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,33 +7006,The client was referred for evaluation of cataracts bilaterally,20 +2733, Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,33 +7366,Occupational medicine consult with questions-answers and records review.,18 +1389, Endoscopic proximal shunt revision.,23 +494, A 34-year old female with no fetal heart motion noted on office scan.,24 +11986,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +9967,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7819,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +11994,Dietary consultation for diabetes during pregnancy.,9 +4760,An example/template for a routine normal male physical exam.,25 +10975,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +1480, Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.,38 +18," Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled. ",24 +4813,"Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",10 +7879,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +9291,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8600,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +9595,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +810, Dysarthria. Probable brainstem glioma.,5 +2841," A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis",15 +7986,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +343, Carotid artery angiograms.,33 +531, An example/template for a routine normal male physical exam.,25 +844," Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 +11770,Cause of death - Anoxic Encephalopathy,1 +9046,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11304,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +12119,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +738, A 12-year-old with discoid lupus on the control with optimal regimen.,5 +3861," Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.",27 +2655, Rhabdomyosarcoma of the left orbit. Left subclavian vein MediPort placement. Needs chemotherapy.,38 +4939,Left retrosigmoid craniotomy and excision of acoustic neuroma.,23 +7854,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +3845," The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.",11 +3342," Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",3 +241," Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. ",37 +2460," A 44-year-old, 250-pound male presents with extreme pain in his left heel.",38 +9712,A sample note on Rheumatoid Arthritis,34 +3415, Sellar HCT - Pituitary mass,22 +3970, Left laparoscopic hand-assisted nephrectomy.,21 +5130,"Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",39 +2444, Completion thyroidectomy with limited right paratracheal node dissection.,13 +5264,"Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.",11 +11449,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +7927,Patient referred for narrow angles and possible associated glaucoma.,20 +7734,Chiropractic IME with answers to questions from Insurance Company.,20 +7997,Autopsy - Homicide - Blunt force cranial trauma,1 +3381, Patient with swelling of lips and dysphagia and Arthritis.,5 +1655," Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.",14 +6714,Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 +10245,Preop evaluation regarding gastric bypass surgery.,2 +5835,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 +3472, Permacath placement - renal failure.,38 +3206, Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,29 +9855,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2942, Stress test with Bruce protocol due to chest pain.,33 +5896,Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +4650,CT Abdomen and Pelvis with contrast,21 +11034,Mother states he has been wheezing and coughing.,0 +9116,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +5866,"Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 +4410,"Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",23 +7185,Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 +4640,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 +1888, Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +8840,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +5424,"Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to healthcare therapy, severe anemia, and fibroid uterus.",10 +7522,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6828,13 years old complaining about severe ear discomfort - Chronic otitis media.,11 +11087,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1941," MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.",27 +7851,Evaluation for bariatric surgery.,2 +458, Circumcision procedure in a baby,38 +7344,Patient presents for care of suspected rheumatoid arthritis.,34 +554," Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",5 +3649, Laparoscopic cholecystectomy. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,38 +8737,Evaluation for bariatric surgery.,2 +9272,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +11337,"Followup diabetes mellitus, type 1.",13 +5465,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,24 +7292,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6110,Right ear discomfort with drainage - otitis media and otorrhea.,11 +10906,Dietary consultation for carbohydrate counting for type I diabetes.,9 +11695,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2113," Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",31 +4, Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,15 +8782,Dietary consultation for gestational diabetes.,9 +7136,Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 +7160,Qualified healthcare evaluation report of a patient with back pain.,4 +2031," Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",5 +9134,Autopsy of a white female who died of acute combined drug intoxication.,1 +12589,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10181,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +8369,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +3366, History of right leg pain. Leg pain is no longer present.,35 +9872,Dietary consultation for diabetes during pregnancy.,9 +4128,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8184,Cause of death - Anoxic Encephalopathy,1 +2784, Sample progress note - Gen Med.,15 +9608,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7249,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +6840,Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.,29 +4454,"Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past clinical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.",22 +11690,Mother states he has been wheezing and coughing.,0 +4169,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +7848,Work restrictions and disability evaluation,18 +9664,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5177,A 60-year-old female presents today for care of painful calluses and benign lesions.,31 +5294,"Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 +3019, Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,38 +5456,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +2580, Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.,14 +10657,A 23-year-old white female presents with complaint of allergies.,0 +3476, The patient is admitted with a diagnosis of acute on chronic renal insufficiency.,5 +7616,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +6079,Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,10 +5629,Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest ache,25 +8282,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +8241,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +10486,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3645," Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.",38 +3224," Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.",27 +2430, Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,14 +12210,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +1222, A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,16 +5412,This client was seen in clinic for a school physical.,29 +7137,Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 +8147,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +4141,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +11466,Cause of death - Anoxic Encephalopathy,1 +84," A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",23 +9865,Dietary consultation for gestational diabetes.,9 +12586,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2981," Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",27 +11372,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +8040,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +7250,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +11936,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +7368,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +3359," Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",16 +4599,"Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.",22 +11470,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +1928, MRI cervical spine.,22 +3014, Right ear pain with drainage - otitis media and otorrhea.,5 +4384,Bilateral renal ultrasound.,33 +3421," MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.",33 +4784,The client was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,32 +11323,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +11794,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1016," Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",22 +10163,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +7964,Blepharoplasty procedure,6 +50," Right shoulder impingement syndrome, right suprascapular neuropathy.",22 +4014,Patient with increased shortness of breath of one day duration.,15 +8931,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +5644,"Re-excision of squamous cell carcinoma site, right hand.",16 +5027,"Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 +7321,A sample note on Rheumatoid Arthritis,34 +508, Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.,38 +971," The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",22 +6897,Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 +4609,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +3010," Right hand laceration x3, repaired.",15 +8031,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +12311,Patient presents for care of suspected rheumatoid arthritis.,34 +9503,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12300,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8924,"Specimen labeled ""sesamoid bone left foot"".",19 +11610,A 23-year-old white female presents with complaint of allergies.,0 +7805,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +6903,Sample post dilation case instructions.,26 +2873, Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,3 +142, Resting Myoview and adenosine Myoview SPECT,33 +1326, Lower Extremity Arterial Doppler,3 +11213,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +8583,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6124,"Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.",21 +2792, A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,15 +7905,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11086,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6073,The patient's main complaint is vertigo. The case is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +8953,Consultation for left foot pain.,4 +10489,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12351,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10945,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2418," Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.",38 +11176,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6609,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +412," Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. ",11 +10658,Work restrictions and disability evaluation,18 +9489,A sample note on Rheumatoid Arthritis,34 +6901,"The case is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.",16 +10324,Consultation for wrist pain.,4 +7235,"Specimen labeled ""sesamoid bone left foot"".",19 +4042,Common description of colonoscopy,14 +11786,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +9639,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3585, Dietary consultation for carbohydrate counting for type I diabetes.,9 +11266,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +8875,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5207,"Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +3971," Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",23 +8430,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7480,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +193," Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 +11034,Mother states he has been wheezing and coughing.,0 +5432,Emergency cesarean section.,24 +12475,Cause of death - Anoxic Encephalopathy,1 +2265, The patient has a possibly torsion detorsion versus other acute testicular problem. ,12 +7940,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +1514," First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",15 +11228,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +1562," Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",38 +6258,Psychosocial evaluation of kidney donor. Questions - Answers,32 +9528,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +4269,Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.,15 +1686," Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue",15 +3933," Intercostal block from fourth to tenth intercostal spaces, left. Chest pain secondary to fractured ribs, unmanageable with narcotics.",28 +5343,Occupational medicine consult with questions-answers and records review.,18 +3970, Left laparoscopic hand-assisted nephrectomy.,21 +1559," Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.",15 +75, Patient with a history of ischemic cardiac disease and hypercholesterolemia.,3 +637, Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 +12628,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4470,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The client was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 +2839," Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",38 +1651, Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 +3000," Missed abortion. Suction, dilation, and curettage.",24 +11622,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6353,"Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +1081," Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",38 +9140,Autopsy of a white female who died of acute combined drug intoxication.,1 +2026, Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,25 +773, Duplex ultrasound of legs,33 +2010, Letter to the patient to let him know about his abnormal cholesterol test results.,20 +8148,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +9938,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +5327,Cystoscopy. Transurethral resection of the prostate.,39 +4932,"Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",39 +5926,"An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",12 +9539,Cause of death - Anoxic Encephalopathy,1 +12397,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +5478,Trauma/ATV accident resulting in left open humerus fracture.,10 +6249,Autopsy of a white female who died of acute combined drug intoxication.,1 +9686,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2355, Whole body radionuclide bone scan due to prostate cancer.,39 +1086, Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,38 +5755,Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 +11714,A sample note on Rheumatoid Arthritis,34 +4559,Falls at home. Anxiety and depression. The case had been increasingly anxious and freely admitted that she was depressed at home.,22 +8497,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +4837,Nephrology office visit for followup of microscopic hematuria.,21 +10626,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4463,Patient in ER with upper respiratory infection,12 +8560,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +1421," Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.",33 +8835,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +11455,Evaluation for chronic discomfort program,4 +2328," Needle-localized excisional biopsy, left breast. The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast. She had no palpable mass on physical exam. She does have significant family history with two daughters having breast cancer.",38 +5376,Difficulty with both distance vision and with fine print at near.,26 +6983,Patient with right ankle pain.,31 +463, Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,5 +2584, MRI Brain - Olfactory groove meningioma.,33 +7759,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +6338,Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The client is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.,11 +10781,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +6394,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +2348," Chest, Single view post OP for ASD (Atrial Septal Defect).",33 +8033,Letter to the case to let him know about his abnormal cholesterol test results.,20 +10715,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4088,"Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",16 +4629,"Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",29 +5331,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +3556, Patient was found to have decrease in mental alertness,15 +9147,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +12020,Mother states he has been wheezing and coughing.,0 +8201,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +656, Hardware removal in the left elbow.,38 +7442,Autopsy - Homicide - Blunt force cranial trauma,1 +5611,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.,12 +11032,Mother states he has been wheezing and coughing.,0 +5155,a pleasant 62-year-old male with cerebral palsy,10 +10351,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The case fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +1140, Right upper quadrant pain. Nuclear medicine hepatobiliary scan. Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,14 +461, Laparoscopic cholecystectomy with cholangiogram.,38 +7979,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +5538,"Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",23 +3574, Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,38 +8149,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +7309,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7953,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +10116,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +7933,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +11533,Work restrictions and disability evaluation,4 +9869,Dietary consultation for diabetes during pregnancy.,9 +1466," A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",15 +7161,Qualified healthcare evaluation report of a patient with back pain.,4 +1378," Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",22 +2253, Admission Psychiatric Evaluation,32 +4118,"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 +12203,Is it BNP or BMP?,19 +7843,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +4293,"Followup diabetes mellitus, type 1.",35 +217," A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. ",14 +7318,A sample note on Rheumatoid Arthritis,34 +3214," Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.",3 +8114,Completion thyroidectomy with limited right paratracheal node dissection.,13 +3944, MRI Elbow - A middle-aged female complaining of elbow pain.,33 +11082,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2907," Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.",5 +12302,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10594,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +9749,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8437,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +5042,Psychosocial Evaluation of client before kidney transplant.,32 +20, Total colonoscopy with biopsy and snare polypectomy.,14 +4441,"Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 +11388,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +10992,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1554," Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes.",22 +1924, Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +2276, Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,35 +9335,Elevated cholesterol and is on medication to lower it.,9 +2347," An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis.",15 +11694,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7606,Autopsy - Homicide - Blunt force cranial trauma,1 +11593,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2274, A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,38 +6404,"Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The client is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.",23 +2594, Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,35 +504," This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.",5 +1399," Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.",38 +11926,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.",30 +12577,Is it BNP or BMP?,19 +9297,Autopsy - Asphyxia due to ligature strangulation.,1 +5886,"Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",23 +2775, Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.,14 +8661,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +2887," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +6656,"Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",16 +1136, Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 +8032,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11064,Autopsy of a white female who died of acute combined drug intoxication.,1 +5039,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The case is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +1116," D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining. +6. Grade 1+ rectocele.",38 +6973,"Female with intermittent rectal bleeding, not associated with any weight loss. The case is chronically constipated.",20 +371, Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. ,29 +8732,Evaluation for bariatric surgery.,2 +3487, Patient with right ankle pain.,31 +11724,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +7316,A sample note on Rheumatoid Arthritis,34 +6082,"Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",10 +330, Sample for Neuropsychological Evaluation,32 +3047, Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.,38 +10888,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5027,"Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 +7115,"Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.",28 +10625,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4604,Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.,23 +1608," Congestion, tactile temperature.",5 +1495, MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,22 +4436,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",35 +5833,"The case underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the case had improved.",10 +7756,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +9636,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12306,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +351, A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 +4310,"Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 +11214,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +10683,Dietary consultation for gestational diabetes.,9 +7513,Elevated cholesterol and is on medication to lower it.,9 +6341,Completion thyroidectomy with limited right paratracheal node dissection.,13 +11045,Autopsy - Homicide - Blunt force cranial trauma,1 +177," Possible exposure to ant bait. She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.",5 +6449,Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal discomfort for the last 14 days.,12 +6734,Phacoemulsification with posterior chamber intraocular lens insertion.,26 +11558,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8528,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +10026,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +5844,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +76," Uvulopalatopharyngoplasty and tonsillectomy. The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.",38 +2599, Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,10 +10673,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9139,Autopsy of a white female who died of acute combined drug intoxication.,1 +4776,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +3846," Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.",15 +3423," Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.",38 +3208, Consultation for jaw pain.,5 +2238, Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis.,15 +7460,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +1033, Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,33 +8371,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +6799,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",31 +1576, Concomitant chemoradiotherapy for curative intent patients.,33 +298," Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.",27 +7682,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10399,Incision and drainage of right buccal space abscess and teeth extraction.,7 +1550, Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.,27 +12350,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7625,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6684,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 +5735,"Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",11 +11417,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +2275, Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,38 +5962,Lower lid blepharoplasty.,26 +4757,Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,28 +4583,"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",29 +9572,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6165,Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 +10591,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2449, Standard hypogastric plexus block procedure note.,28 +2469," Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",25 +12375,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +2710, Consult and Spinal fluid evaluation in a 15-day-old,38 +11160,A sample note on Rheumatoid Arthritis,34 +7983,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +11386,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +2065, MRI left knee without contrast.,33 +7359,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +3005," Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.",24 +3244, A sample note on pre-eclampsia & eclampsia.,24 +2016, Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.,38 +4739,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",26 +2845, Nuclear Medicine Therapy Intraarterial Particulate Administration,33 +5452,"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.",29 +12610,A sample note on Rheumatoid Arthritis,34 +91," Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",38 +8697,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +6385,"Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 +9189,Consult for laparoscopic gastric bypass.,2 +9431,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2506, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,38 +2223," Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",15 +5097,Urine leaked around the ostomy site for his right sided nephrostomy tube. The client had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 +11385,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11415,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +2148, Bilateral open Achilles lengthening with placement of short leg walking cast.,38 +7388,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +282," Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",24 +8708,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +2891," The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. ",35 +10860,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11264,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +7132,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.",31 +6938,"Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.",28 +3256, Trabeculectomy with mitomycin C - Sample/Template.,38 +2686, Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,10 +11486,Patient scheduled for laparoscopic gastric bypass.,2 +7397,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +690, Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.,14 +11047,Autopsy - Homicide - Blunt force cranial trauma,1 +3691, Consult for prostate cancer,39 +7776,An example/template for a routine normal male physical exam.,25 +5138,A 23-year-old white female presents with complaint of allergies.,35 +3191, The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,24 +10531,Occupational medicine consult with questions-answers and records review.,18 +4829,"Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative clinical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",24 +6468,"Psychiatric evaluation for ADHD, combined type.",32 +9169,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +8529,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +3221," Emergent subxiphoid pericardial window, transesophageal echocardiogram.",38 +8988,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8052,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +10897,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +10539,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +2996, Migraine headache - The patient was seen in the urgent care.,15 +11181,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +720, Right and Left carotid ultrasound ,33 +11089,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3850, Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.,28 +10926,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8742,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +12324,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1942, Newborn circumcision. The penile foreskin was removed using Gomco. ,38 +3450," Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.",38 +1552, Routine colorectal cancer screening. He occasionally gets some loose stools. ,14 +3573," Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.",27 +9714,A sample note on Rheumatoid Arthritis,34 +333," Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.",27 +1645, Mother states he has been wheezing and coughing.,29 +2041, Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. ,38 +1447," An 18-year-old white female who presents for complete physical, Pap, and breast exam.",24 +9108,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +10179,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +10365,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +2754," A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.",39 +10610,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +3082, Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 +325," The patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +934," Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.",39 +1077," Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +7481,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +380, Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,33 +12399,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +3215, Diagnosis of bulbar cerebral palsy and hypotonia. ,22 +12364,Occupational medicine consult with questions-answers and records review.,18 +11285,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +7487,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +385," A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. ",10 +1177, Neurologic examination sample. ,5 +4087,"Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",16 +3392," The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. ",3 +9567,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +6278,"Acute foot or ankle sprain, possible small fracture.",31 +2261," Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.",5 +3569," Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable.",3 +3209, Acne with folliculitis.,8 +7936,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +329," Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 +9043,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +12083,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4187,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",35 +11422,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +2406," Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",38 +10332,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +6775,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 +6401,Punch biopsy of right upper chest skin lesion.,8 +11681,"Specimen labeled ""sesamoid bone left foot"".",19 +9607,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4963,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +11367,Autopsy - Homicide - Blunt force cranial trauma,1 +11236,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +6211,4-day-old with hyperbilirubinemia and heart murmur.,29 +10292,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +821," 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.",38 +6626,"Patient with a history of PTSD, depression, and substance abuse.",32 +8164,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +12064,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +9774,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +274, Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,5 +5895,Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +747, Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,38 +8119,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +9254,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +11866,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9171,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +2450, Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,38 +11427,Occupational medicine consult with questions-answers and records review.,18 +7288,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4098,Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +8195,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +12340,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1752," Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.",35 +10289,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +6975,"Female with intermittent rectal bleeding, not associated with any weight loss. The case is chronically constipated.",20 +12490,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +200," Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 +5669,"The client had hematuria, and unable to void. The client had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.",39 +12022,Mother states he has been wheezing and coughing.,0 +10677,Dietary consultation for gestational diabetes.,9 +10959,Patient presents for therapy of suspected rheumatoid arthritis.,34 +746, Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,14 +10711,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8587,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6669,Psychiatric consultation for alcohol withdrawal and dependance.,32 +8388,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +467," Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.",27 +1273, Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,26 +1735," A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",5 +3887, Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.,38 +1073," Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2",5 +6874,"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.",23 +406, Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,11 +10224,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +3552, Laparoscopic-assisted vaginal hysterectomy. Abnormal uterine bleeding. Uterine fibroids.,24 +12360,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10458,"The case with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +9716,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +10453,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +1070, Penile injury and continuous bleeding from a penile laceration.,12 +4116,"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 +3465," Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ",38 +8986,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +1813," Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",23 +8930,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +3170, Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 +12316,Patient presents for therapy of suspected rheumatoid arthritis.,34 +8911,"Followup diabetes mellitus, type 1.",13 +2834," Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.",27 +11797,Autopsy - Asphyxia due to ligature strangulation.,1 +6257,Psychosocial evaluation of kidney donor. Questions - Answers,32 +10557,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4564,Routine colorectal cancer screening. He occasionally gets some loose stools.,16 +1973, A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.,35 +11096,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +9170,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +4102,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 +10395,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +462," Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.",14 +7464,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5675,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 +7943,A simple note on Acne Vulgaris.,8 +2509," A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",15 +10847,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +2192, Carotid Ultrasonic & Color Flow Imaging,3 +7302,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12035,MRI report Cervical Spine (Chiropractic Specific),4 +1697," 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.",15 +8779,Dietary consultation for gestational diabetes.,9 +3350, Intrauterine pregnancy at term with previous cesarean. Desired sterilization. Status post repeat low transverse cesarean and bilateral tubal ligation.,24 +4133,"Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 +187," Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",16 +11167,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +4295,"Followup diabetes mellitus, type 1.",35 +1725, The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,3 +2944," Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.",24 +10301,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +389," A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.",38 +10693,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7872,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +11218,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6136,A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The client was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,12 +10905,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +3149, Lumbar puncture with moderate sedation.,22 +7097,"Total thyroidectomy. The case is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +3500, Right foot series after a foot injury.,33 +956, Endoscopic proximal shunt revision.,38 +11728,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +873, Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 +12578,Is it BNP or BMP?,19 +8620,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +4690,Patient with a long history of depression and attention deficits.,32 +4090,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 +1836," Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.",10 +3452, Patient with a 1-year history of progressive anterograde amnesia,5 +7169,Elevated cholesterol and is on medication to lower it.,9 +2836," 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.",27 +629," Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 +3931," A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. ",3 +11549,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7735,Chiropractic IME with answers to questions from Insurance Company.,20 +7272,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10065,Occupational medicine consult with questions-answers.,18 +10012,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +2331, An example/template for a routine normal male physical exam.,25 +6714,Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 +7198,"Records review. The patient developed shooting discomfort about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +4842,Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,24 +2132," Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",27 +5127,"Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",10 +8008,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +10756,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11293,Is it BNP or BMP?,19 +6816,Coccygeal injection,28 +9053,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +1691, Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,31 +3918, Open reduction and internal fixation of left tibia.,38 +8601,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +3447, A female for a complete physical and follow up on asthma with allergic rhinitis.,15 +5662,1-year well child check.,29 +9747,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7917,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +8358,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent clinical evaluation.,18 +935, MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.,22 +12387,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +8532,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +2085," This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. ",32 +2440, Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. ,11 +6337,Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The client is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.,11 +5578,Endoscopic proximal shunt revision.,23 +1800, Dysarthria. Probable brainstem glioma.,22 +1915, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,21 +8618,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +6717,Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 +10589,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +8932,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +410," Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.",14 +7688,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +1209," Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.",38 +9725,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12208,Is it BNP or BMP?,19 +7876,Is it BNP or BMP?,19 +5063,"This is a 53-year-old man, who presented to emergency room with multiple complaints including discomfort from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.",12 +1804, Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +7922,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating discomfort in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +3166," Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.",38 +1151, 2-D M-Mode. Doppler. ,33 +2444, Completion thyroidectomy with limited right paratracheal node dissection.,13 +5901,"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",16 +2288," Orthopedic progress note for follow up of osteoarthritis, knees.",35 +1168," Skull, complete, five images.",29 +8508,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +5801,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +762," Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",3 +9266,Dietary consultation for carbohydrate counting for type I diabetes.,9 +7086,"Sample normal ear, nose, mouth, and throat exam.",25 +9421,Is it BNP or BMP?,19 +11192,Occupational medicine consult with questions-answers and records review.,18 +4772,The client states that he feels sick and weak.,35 +12476,Cause of death - Anoxic Encephalopathy,1 +5770,Blepharoplasty procedure,6 +12181,A 23-year-old white female presents with complaint of allergies.,0 +12034,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +819," Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 +6488,The patient continues to suffer from ongoing neck and lower back discomfort with no recent radicular complaints.,25 +545, Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.,27 +1333, Consult for laparoscopic gastric bypass.,5 +10230,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +6812,"Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,",8 +150," The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 +1771," Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.",38 +8199,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The case fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +4941,"Counting calorie points, exercising pretty regularly, seems to be doing well",35 +9876,Dietary consultation for diabetes during pregnancy.,9 +592," Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.",27 +5602,Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The case is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.,29 +7775,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +10101,Dietary consultation for diabetes during pregnancy.,9 +5283,"Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the client has had multiple catheterizations recently and has history of peripheral vascular disease.",39 +1481, Noncontrast CT head due to seizure disorder.,33 +7514,Elevated cholesterol and is on medication to lower it.,9 +8307,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 +8034,Letter to the client to let him know about his abnormal cholesterol test results.,20 +4148,"Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",11 +6385,"Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 +3657, Invasive carcinoma of left breast. Left modified radical mastectomy.,16 +2823, Common description of colonoscopy,14 +6037,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11650,Dietary consultation for diabetes during pregnancy.,9 +8733,Evaluation for bariatric surgery.,2 +2745," The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.",10 +10737,"Specimen labeled ""sesamoid bone left foot"".",19 +3985," Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",38 +7657,Patient presents for care of suspected rheumatoid arthritis.,34 +4921,Frontal and lateral views of the hip and pelvis.,29 +12388,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +11092,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2193, Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,38 +7691,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +5631,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +4330,"Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.",22 +11124,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5258,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.,23 +3178, Arthroscopic procedure of the knee.,27 +8428,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +11313,Dietary consultation for diabetes during pregnancy.,9 +750," Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.",38 +8023,A 21-channel digital electroencephalogram was performed on a case in the awake state.,36 +1822," Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.",38 +1812, Sample female physical exam,15 +9497,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +10974,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3856," Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",38 +2277," Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",11 +821," 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.",38 +12313,Patient presents for care of suspected rheumatoid arthritis.,34 +1054," Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.",5 +11634,Is it BNP or BMP?,19 +8961,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +11538,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +12638,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8320,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +4209,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +3529, The patient needs refills on her Xanax,25 +12647,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10323,Consultation for wrist pain.,4 +8672,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +12215,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8229,Qualified medical evaluation report of a case with back pain.,18 +4565,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent identification of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +6484,Falls at home. Anxiety and depression. The client had been increasingly anxious and freely admitted that she was depressed at home.,32 +10830,Autopsy of a white female who died of acute combined drug intoxication.,1 +9764,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5980,"Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",10 +5038,"Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The client is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +7321,A sample note on Rheumatoid Arthritis,34 +6384,"Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 +6956,Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The client 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.,29 +6982,Patient with right ankle pain.,31 +12602,Autopsy - Homicide - Blunt force cranial trauma,1 +3766," Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",10 +8879,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating discomfort in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +1617," Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.",38 +1558, 2-month-old female - increased work of breathing.,12 +5143,Work restrictions and disability evaluation,18 +1811," Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.",38 +6898,Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 +5939,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +10939,Autopsy - Asphyxia due to ligature strangulation.,1 +10569,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +1610," 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.",15 +11571,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +8284,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +5897,"The patient is a 93-year-old Caucasian female with a past clinical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",10 +6405,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +10815,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +8336,Autopsy - Asphyxia due to ligature strangulation.,1 +567," Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.",33 +2538," A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study. ",33 +9844,A 23-year-old white female presents with complaint of allergies.,0 +11506,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +3117," CT Brain: Suprasellar aneurysm, pre and post bleed.",22 +2816," Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.",22 +1906," Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy",38 +2386, CCTA with cardiac function and calcium scoring.,3 +9003,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +6335,"Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",11 +8766,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +3174, Coccygeal injection,28 +4985,Patient with fever of unknown origin.,10 +6355,"Normal review of systems template. The client denies fever, fatigue, weakness, weight gain or weight loss.",25 +6088,Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 +11754,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +7291,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7294,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3513," One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.",15 +3570," The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. ",5 +251," Anxiety, alcohol abuse, and chest pain. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. ",5 +4797,"CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",22 +7284,Patient presents for care of suspected rheumatoid arthritis.,34 +8, Patient complains of chest pain - possible esophageal reflux,3 +5091,"Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",11 +2941, The patient had spraying of urine and ballooning of the foreskin with voiding.,39 +9997,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +3998," Upper endoscopy, patient with dysphagia.",38 +6373,Well child - Left lacrimal duct stenosis,29 +10914,Dietary consultation for carbohydrate counting for type I diabetes.,9 +9637,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1950, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,12 +6247,Patient presents with a chief complaint of chest discomfort admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 +2864," T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",16 +1114, An example/template for a routine normal male physical exam.,5 +7323,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +4675,"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 +6657,Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 +6830,13 years old complaining about severe ear discomfort - Chronic otitis media.,11 +1129, ,22 +2220, A well-child check with concern of some spitting up quite a bit.,29 +12587,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11862,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8575,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +3407," Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",10 +5410,"Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye.",26 +8392,Work restrictions and disability evaluation,4 +9521,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +2494, MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,33 +10051,The case is being referred for evaluation of diabetic retinopathy.,20 +9522,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +12642,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11779,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12092,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +12660,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7187,Evaluation and recommendations regarding facial rhytids.,8 +117, Procedure note on Keller Bunionectomy,31 +900, Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.,5 +5751,"Phacoemulsification of cataract, extraocular lens implant in left eye.",26 +11547,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9196,Consultation for wrist pain.,4 +1849," Pelvic tumor, cystocele, rectocele, and uterine fibroid. Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ",38 +10938,Autopsy - Asphyxia due to ligature strangulation.,1 +12498,Autopsy - Asphyxia due to ligature strangulation.,1 +11440,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +7000,"The case is 14 months old, comes in with a chief complaint of difficulty breathing.",12 +6186,"Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 +7159,Qualified medical evaluation report of a case with back pain.,4 +4945,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +10929,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4553,A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 +8604,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +1619," Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",11 +3532," Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.",38 +11746,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +6981,Itchy red rash on feet - Tinea Pedis,31 +10397,Incision and drainage of right buccal space abscess and teeth extraction.,7 +8695,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +9627,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8038,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +2982," A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. ",29 +7243,Autopsy - Homicide - Blunt force cranial trauma,1 +6621,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +3485," Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, +and congestive heart failure.",14 +2941, The patient had spraying of urine and ballooning of the foreskin with voiding.,39 +12392,Chiropractic IME with answers to questions from Insurance Company.,4 +2821, Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.,39 +9430,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4626,"Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear.",11 +10182,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +8952,Consultation for left foot pain.,4 +10799,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +4430,Newly diagnosed head and neck cancer. The client was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 +7376,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3909, A 2-month-old female with 1-week history of congestion and fever x2 days.,5 +1142," EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +3271, A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,12 +5212,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +5374,Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 +4153,Normal upper GI endoscopy.,14 +1152, Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,3 +7204,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +1795, Right undescended testicle. Orchiopexy & Herniorrhaphy.,39 +8025,MRI report Cervical Spine (Chiropractic Specific),4 +11334,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +8854,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +11603,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4291,"Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 +2782," Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",5 +8648,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +7662,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11283,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +11452,Consultation for wrist pain.,4 +6388,"Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",26 +8217,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 +2868, Frontal and lateral views of the hip and pelvis.,27 +919," Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",39 +12129,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7022,An example/template for a routine normal female physical exam.,25 +3801, a pleasant 62-year-old male with cerebral palsy,22 +622," Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 +4750,"Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder discomfort and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.",35 +4425,CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,11 +10253,"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.",6 +6223,Admission Psychiatric Evaluation,32 +12480,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8455,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +1704, An example/template for meatoplasty.,38 +4326,"Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 +6911,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,29 +810, Dysarthria. Probable brainstem glioma.,5 +3440, Ultrasound-Guided Paracentesis for Ascites,38 +12036,MRI report Cervical Spine (Chiropractic Specific),4 +10462,Patient presents for therapy of suspected rheumatoid arthritis.,34 +6389,"Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",26 +9281,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +4333,"Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",10 +4315,"Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",16 +5169,"Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",35 +7895,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +4641,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 +9685,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9349,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +348, Short-term memory loss (probable situational) and anxiety stress issues.,5 +6723,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +10199,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +11074,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11874,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +9363,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9125,Consult for laparoscopic gastric bypass.,2 +11211,Chiropractic IME with answers to questions from Insurance Company.,20 +6600,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The client fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +1081," Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",38 +12190,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8461,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +4385,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 +7461,Autopsy of a white female who died of acute combined drug intoxication.,1 +7435,Mother states he has been wheezing and coughing.,0 +2408," Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.",38 +11283,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +7855,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6739,"A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the identification of intracranial bleeding.",12 +6019,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant.,26 +6242,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +1786, A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy. ,16 +438, Scleral buckle opening under local anesthesia.,38 +1042," The thoracic spine was examined in the AP, lateral and swimmer's projections.",27 +4188,Patient with intermittent episodes of severe nausea and abdominal pain.,15 +3046, Left temporal craniotomy and removal of brain tumor.,23 +9892,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2760, The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.,14 +11439,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +7165,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +11484,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +12076,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8903,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +6531,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +5536,Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,23 +11605,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7773,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +4893,A sample note on bilateral myringotomy tubes,11 +7701,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +8415,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5314,Penile injury and continuous bleeding from a penile laceration.,12 +8107,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +11975,Dietary consultation for gestational diabetes.,9 +6969,"A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.",31 +9013,A sample note on Rheumatoid Arthritis,34 +11548,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4747,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +801, Thoracentesis. Left pleural effusion. Left hemothorax.,38 +9570,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +1823, Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +1779," Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. ",5 +9783,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2005," Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week",39 +6902,"The case is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.",16 +5523,Patient referred for narrow angles and possible associated glaucoma.,20 +7975,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +7991,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8725,Work restrictions and disability evaluation,18 +9277,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +8900,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +2554, Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,38 +11871,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3974, Completion thyroidectomy with limited right paratracheal node dissection.,38 +11055,A sample note on Rheumatoid Arthritis,34 +1847, Intermittent rectal bleeding with abdominal pain.,38 +4826,A 31-year-old white female admitted to the hospital with pelvic discomfort and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 +8088,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +9286,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10167,Chiropractic IME with answers to questions from Insurance Company.,18 +591, Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.,27 +11356,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +425," Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 +9010,A sample note on Rheumatoid Arthritis,34 +12165,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8230,Qualified healthcare evaluation report of a patient with back pain.,18 +4131,"Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 +5959,"A 49-year-old female with ankle ache times one month, without a specific injury.",31 +9301,Autopsy - Asphyxia due to ligature strangulation.,1 +6582,Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.,23 +4157,Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,39 +2425," Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",35 +3875, Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,15 +507, Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 +7778,An example/template for a routine normal male physical exam.,25 +9666,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6943,Chronic snoring in children,36 +3930, Patient with a diagnosis of stroke.,15 +4670,"The case noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",39 +5889,Pain and swelling in the right foot.,31 +7146,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +7060,Quick note on tachypnea.,25 +96, Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. ,38 +7400,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +5, Direct right inguinal hernia. Marlex repair of right inguinal hernia.,39 +10415,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +863," Congestion, tactile temperature.",15 +11186,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10065,Occupational medicine consult with questions-answers.,18 +7486,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +2659," Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +7329,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1672, This is a middle-aged female with two month history of low back pain and leg pain.,33 +11722,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +743," Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. +",6 +9963,Chiropractic IME with answers to questions from Insurance Company.,20 +10813,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9399,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6667,Sepsis. The client was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,16 +9936,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7748,An example/template for a routine normal male physical exam.,25 +8229,Qualified medical evaluation report of a case with back pain.,18 +1911, Lower lid blepharoplasty.,26 +1175," Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. ",38 +130, Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,30 +1431, 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.,12 +5754,Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 +3837, Laparoscopic right radical nephrectomy due to right renal mass.,21 +8255,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +7433,"Specimen labeled ""sesamoid bone left foot"".",19 +1777, Open radical retropubic prostatectomy with bilateral lymph node dissection.,39 +10825,Autopsy of a white female who died of acute combined drug intoxication.,1 +10473,Work restrictions and disability evaluation,4 +833, Right pleural effusion and suspected malignant mesothelioma.,3 +7082,Patient being referred for evaluation of glaucoma.,20 +4176,Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient healthcare therapy.,11 +6894,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +1920, Laparoscopic right partial nephrectomy due to right renal mass.,21 +9578,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10953,Patient presents for care of suspected rheumatoid arthritis.,34 +3136," Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.",5 +10430,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11164,A sample note on Rheumatoid Arthritis,34 +8337,Autopsy - Asphyxia due to ligature strangulation.,1 +7059,Quick note on tachypnea.,25 +8927,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +8416,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4625,"Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear.",11 +2122, Trabeculectomy with mitomycin C - Sample/Template.,26 +4064,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,10 +6100,"This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.",32 +6284,"Discharge summary of case with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",10 +8232,"The case with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +9921,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4511,"Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the client has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.",24 +6923,Complete heart block with pacemaker malfunction and a history of Shone complex.,12 +1304, ,14 +2329, Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,5 +8224,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8799,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +8227,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +8862,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4931,"Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.",11 +2165, CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,33 +1627, MRI Cervical Spine without contrast.,27 +11947,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5203,Normal vasectomy,39 +10895,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3051, Consultation for left foot pain.,27 +2642," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",38 +6333,"Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",11 +9551,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +953, A 17-year-old male with oligoarticular arthritis of his right knee.,5 +1485," Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.",38 +3527, Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,38 +1278," Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +1571, Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,16 +8564,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +3591," Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.",38 +10371,Qualified healthcare evaluation report of a patient with back pain.,18 +8767,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +681, Right orchiopexy and right inguinal hernia repair.,39 +92, Bilateral temporal artery biopsy. Rule out temporal arteritis.,38 +12474,Cause of death - Anoxic Encephalopathy,1 +12372,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10255,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8920,"Specimen labeled ""sesamoid bone left foot"".",19 +8341,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +10958,Patient presents for care of suspected rheumatoid arthritis.,34 +431," Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",38 +11027,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +5887,"Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",23 +8057,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +5249,Dietary consultation for gestational diabetes.,9 +4486,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 +2119," Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.",27 +2949," Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.",38 +2478," Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",33 +4224,Patient with episode of lightheadedness and suddenly experienced vertigo.,22 +8926,"Specimen labeled ""sesamoid bone left foot"".",19 +5591,Psychiatric History and Physical - Patient with schizoaffective disorder.,32 +1104, Sample/template for a normal male multisystem exam.,5 +6532,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +5337,Psychiatric Consultation of case with dementia.,32 +3175," Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +7928,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +5121,A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 +6024,"Intercostal block, left. Severe post thoracotomy pain.",28 +4983,Patient with fever of unknown origin.,10 +5207,"Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +2929, A 66-year-old female with knee osteoarthrosis who failed conservative management.,27 +3470, Patient with a three-day history of emesis and a four-day history of diarrhea,35 +2419," Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.",38 +11645,Dietary consultation for diabetes during pregnancy.,9 +438, Scleral buckle opening under local anesthesia.,38 +4593,Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,26 +3544," Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",5 +522," Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. +",27 +4028,"Laparoscopic tubal sterilization, tubal coagulation.",24 +522," Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. +",27 +11245,Chiropractic IME with answers to questions from Insurance Company.,4 +2356, Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,10 +11938,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +1930, Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,38 +9576,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2404, Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +4566,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent determination of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +6393,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +272, Upper endoscopy with foreign body removal (Penny in proximal esophagus).,14 +7527,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4664,"Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",26 +7127,"Questionable foreign body, right nose. Belly and back pain. Mild constipation.",29 +4743,"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient therapy and increased mood lability.",32 +10159,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +4202,"Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 +11238,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +9356,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9170,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +9862,Dietary consultation for gestational diabetes.,9 +10525,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2737," Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",32 +5099,Urine leaked around the ostomy site for his right sided nephrostomy tube. The client had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 +6785,MRI right ankle.,31 +9929,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +8259,Acne with folliculitis.,8 +10348,Cause of death - Anoxic Encephalopathy,1 +10124,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +2424, Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,38 +5293,"Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.",11 +6959,"Gangrene osteomyelitis, right second toe. The case is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The case has history of previous right foot infection requiring first ray resection.",31 +7608,A sample note on Rheumatoid Arthritis,34 +9152,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +9777,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1487, Left partial nephrectomy due to left renal mass.,38 +2900, The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,38 +3626," Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.",38 +1829," Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.",16 +7643,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2522, Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +6238,"A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.",10 +4110,Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,11 +6239,"Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",11 +8055,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +7869,Dietary consultation for gestational diabetes.,9 +3312, A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. ,22 +7454,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +5615,Normal vasectomy,39 +10629,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11218,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9331,Elevated cholesterol and is on medication to lower it.,9 +1305, Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,38 +5114,"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 +3424," Severe tonsillitis, palatal cellulitis, and inability to swallow.",5 +4322,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +12571,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9592,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2824," A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. ",5 +7979,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +11580,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11399,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +4736,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",10 +1674," Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +11730,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +7299,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +924, The patient is being referred for evaluation of diabetic retinopathy.,20 +305," Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot.",38 +9360,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9210,Evaluation for chronic ache program,4 +1890, Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,14 +6061,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +3990," Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.",39 +10368,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1892, Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,22 +2473, CT of the abdomen and pelvis without contrast.,33 +10674,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7842,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +3434, Revision right total knee arthroplasty. Right failed total knee arthroplasty.,38 +10618,Chiropractic IME with answers to questions from Insurance Company.,4 +9604,Patient presents for care of suspected rheumatoid arthritis.,34 +1492, A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation.,14 +8651,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +11580,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10311,Patient today with ongoing issues with diabetic control.,13 +9306,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +4935,Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 +3017," Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.",27 +11774,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5649,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",31 +5782,Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.,31 +9824,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2239, Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,39 +1339, Psychiatric consultation for substance abuse.,32 +2294, Invasive carcinoma of left breast. Left modified radical mastectomy.,38 +6727,L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,28 +9665,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11474,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +3309," Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",39 +11143,A sample note on Rheumatoid Arthritis,34 +7303,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8997,Autopsy - Homicide - Blunt force cranial trauma,1 +943," Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",12 +4447,Followup circumcision. The case had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 +1874, Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. ,39 +7856,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +7901,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +6860,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The client is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",29 +1694, Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,35 +10263,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +6430,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 +10498,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +12418,Dietary consultation for diabetes during pregnancy.,9 +12028,Autopsy - Homicide - Blunt force cranial trauma,1 +2706, CT of Brain - Subacute SDH.,22 +11668,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +8630,Chiropractic IME with answers to questions from Insurance Company.,4 +7707,Occupational medicine consult with questions-answers and records review.,18 +10951,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3940, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,15 +6622,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +11226,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +5671,"The client had hematuria, and unable to void. The client had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.",39 +3866, Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,3 +12661,A sample note on Rheumatoid Arthritis,34 +2735, Direct laryngoscopy and bronchoscopy.,3 +2169," Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.",38 +4568,"Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck ache",35 +7401,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +11695,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +5033,"Plantar fascitis, left foot. Partial plantar fasciotomy.",31 +10985,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10839,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4578,Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.,29 +3822, Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.,5 +3494," Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.",5 +6038,Generalized abdominal ache with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,21 +5893,Autopsy - Homicide - Blunt force cranial trauma,1 +5818,Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,10 +4097,"Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +3443, Patient with history of polyps.,14 +10746,Mother states he has been wheezing and coughing.,0 +981, Normal vasectomy,39 +6972,Cervical Selective Nerve Root Block,28 +6632,"Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +8329,"Total thyroidectomy. The case is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +4573,A woman presents for neurological evaluation with regards to a identification of multiple sclerosis.,22 +2793, Patient presents for treatment of suspected rheumatoid arthritis.,5 +9229,Cause of death - Anoxic Encephalopathy,1 +3063," EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.",38 +11426,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +10415,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +2615," Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",38 +12497,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11332,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +3736," Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.",15 +4890,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,35 +2887," Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +11624,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6572,Psychiatric consultation of case with lethargy.,32 +3536, Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. ,5 +3193," A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",22 +3323, Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 +8501,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +5487,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +1074," A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",29 +7760,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +6719,Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 +6315,Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 +12520,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4490,Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,23 +4611,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +11598,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10139,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +4365,Patient dropped a weight on the dorsal aspects of his feet.,31 +886," Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).",38 +11478,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12312,Patient presents for care of suspected rheumatoid arthritis.,34 +2372, Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.,14 +8002,Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +6459,Consultation for wrist pain.,4 +10229,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +10122,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +8995,Autopsy - Homicide - Blunt force cranial trauma,1 +7164,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent clinical evaluation.,18 +3751, Problem of essential hypertension. Symptoms that suggested intracranial pathology.,3 +12332,A sample note on Rheumatoid Arthritis,34 +2350," Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.",5 +3469, Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 +9112,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +3389, Pain management sample progress note.,27 +3537," Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. +",38 +8608,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +4865,"Nuclear sclerotic cataract, right eye. Kelman phacoemulsification with posterior chamber intraocular lens, right eye.",26 +372, MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.,3 +11829,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9763,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12007,"Followup diabetes mellitus, type 1.",13 +4472,"Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.",24 +5260,"This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +2451, Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar,33 +12404,A 23-year-old white female presents with complaint of allergies.,0 +6424,"Psychiatric consultation has been requested as the case has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",32 +6275,"Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",31 +6067,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +6071,The patient's main complaint is vertigo. The case is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +584, Chiropractic IME with answers to questions from Insurance Company.,4 +3270, Antibiotic management for a right foot ulcer and possible osteomyelitis.,15 +5797,Mother states he has been wheezing and coughing.,0 +4725,A sample note on Conjunctivitis (Pink Eye).,26 +99, Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. ,3 +10198,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +6233,The case has a possibly torsion detorsion versus other acute testicular problem.,12 +1345, An example/template for a routine normal female physical exam.,5 +9350,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +319, Normal upper GI endoscopy.,38 +9942,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 +8014,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +8624,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +7729,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +9828,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +4623,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +9354,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9972,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.",30 +3927," Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.",38 +11321,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10904,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +8137,Consult for laparoscopic gastric bypass.,2 +3310, Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,38 +10571,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +5690,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 +4905,"Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +1992, Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.,5 +12330,A sample note on Rheumatoid Arthritis,34 +11112,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11520,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10128,Patient referred for narrow angles and possible associated glaucoma.,20 +7860,Occupational medicine consult with questions-answers.,18 +252," Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +2874," A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. ",15 +10698,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +8435,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +12012,"Specimen labeled ""sesamoid bone left foot"".",19 +2555," Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",23 +6693,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5628,Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest ache,25 +11928,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +3689, The patient is brought in by an assistant with some of his food diary sheets.,35 +11441,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +4313,"Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative.",16 +359, Routine colorectal cancer screening. He occasionally gets some loose stools. ,16 +12526,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3198," Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.",3 +1585, Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,22 +213," This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.",21 +2854," Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.",39 +8558,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +10650,A 23-year-old white female presents with complaint of allergies.,0 +4253,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +803," Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",38 +5871,A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.,16 +1299, Patient with worsening shortness of breath and cough.,3 +762," Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",3 +7965,Blepharoplasty procedure,6 +7966,Blepharoplasty procedure,6 +4189,Patient with intermittent episodes of severe nausea and abdominal pain.,15 +307, Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. ,39 +3915," Adenocarcinoma of the prostate. The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. ",39 +11125,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11651,Dietary consultation for diabetes during pregnancy.,9 +826, Psychiatric Consultation of patient with anxiety.,32 +4602,"Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",23 +3656, Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,21 +4549,"Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",26 +3643, No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,3 +3367, This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. ,35 +6148,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +10882,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +9404,A 23-year-old white female presents with complaint of allergies.,0 +2341," Acute foot or ankle sprain, possible small fracture.",31 +3603," Sample normal ear, nose, mouth, and throat exam.",11 +12636,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4852,Followup on chronic kidney disease.,21 +9292,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7989,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 +5098,Urine leaked around the ostomy site for his right sided nephrostomy tube. The case had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 +6656,"Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",16 +11960,A 23-year-old white female presents with complaint of allergies.,0 +10613,Chiropractic IME with answers to questions from Insurance Company.,4 +3705, Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. ,2 +7899,Dietary consultation for diabetes during pregnancy.,9 +12547,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7974,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +10384,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +9547,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12260,A sample note on Rheumatoid Arthritis,34 +1647," Right inguinal hernia. Right inguinal hernia repair. The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",38 +9273,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3093," Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",38 +5304,Stage I and II neuromodulator.,39 +9694,A sample note on Rheumatoid Arthritis,34 +12607,A sample note on Rheumatoid Arthritis,34 +4420,A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the client is 53 months out from transplant.,35 +11659,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4876,Incision and drainage (I&D) of buttock abscess.,8 +2434, Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,38 +3042, Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar,3 +2966, Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 +1753, Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation. ,38 +896," Re-excision of squamous cell carcinoma site, right hand.",38 +3650, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today.,5 +9093,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +10969,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3875, Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,15 +9677,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +35, Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.,38 +10214,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +9270,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +1496," Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.",33 +2764, Patient in ER complaining of shortness of breath (COPD),12 +4469,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The client was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 +8413,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4532,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",35 +11162,A sample note on Rheumatoid Arthritis,34 +7845,The case is being referred for evaluation of diabetic retinopathy.,20 +11947,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7067,"Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The client was given discharge instructions on wound care.",12 +6511,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +652," Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",38 +120," Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 +11882,Patient presents for care of suspected rheumatoid arthritis.,34 +5266,"Excision of nasal tip basal carcinoma, previous positive biopsy.",16 +741, Lumbar epidural steroid injection for lumbar radiculopathy.,28 +2345," Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",10 +10822,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +5364,Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,24 +5882,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +1858, Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,3 +11900,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +8447,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10574,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12213,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11672,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +7885,Occupational medicine consult with questions-answers and records review.,18 +9012,A sample note on Rheumatoid Arthritis,34 +11078,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10520,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5950,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +2811," Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",39 +9669,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7841,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +8130,Punch biopsy of right upper chest skin lesion.,8 +9615,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12295,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1104, Sample/template for a normal male multisystem exam.,5 +7723,Most commonly used phrases in physical exam.,25 +12243,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10188,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +11290,Dietary consultation for gestational diabetes.,9 +12109,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +11799,Autopsy - Asphyxia due to ligature strangulation.,1 +790," This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ",29 +8874,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10032,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +10115,"Patient suffers from neck and lower back discomfort radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +167, Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 +6573,Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,23 +6921,"Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming identification of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.",12 +2431, Ultrasound - a 22-year-old pregnant female.,24 +8786,Is it BNP or BMP?,19 +2074, Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,5 +9452,"Specimen labeled ""sesamoid bone left foot"".",19 +11551,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9410,A 23-year-old white female presents with complaint of allergies.,0 +1274," New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",5 +2056," Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",10 +10943,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +2789," Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.",14 +1577," An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",3 +798," Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment.",27 +3440, Ultrasound-Guided Paracentesis for Ascites,38 +11497,Dietary consultation for carbohydrate counting for type I diabetes.,9 +7637,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2311, Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. ,22 +2688, Belly button piercing for insertion of belly button ring.,38 +11430,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +5324,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +12564,A 23-year-old white female presents with complaint of allergies.,0 +3468," Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated.",20 +2924, Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum. ,38 +11902,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +10599,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +11573,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3889, Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,38 +6752,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 +8410,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12432,Mother states he has been wheezing and coughing.,0 +7042,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,21 +2159, 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.,14 +4851,Followup on chronic kidney disease.,21 +11151,A sample note on Rheumatoid Arthritis,34 +3004, Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,35 +1332," Anxiety, alcohol abuse, and chest pain. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. ",15 +11889,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3302, She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.,38 +5234,"Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",28 +5784,Chiropractic IME with answers to questions from Insurance Company.,18 +1089, Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,23 +12314,Patient presents for therapy of suspected rheumatoid arthritis.,34 +11015,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9339,Elevated cholesterol and is on medication to lower it.,9 +5001,Vaginal discharge with a foul odor.,24 +7090,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +1591, Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,5 +10044,"The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +7885,Occupational medicine consult with questions-answers and records review.,18 +3660, A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,12 +10597,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +2043," Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.",14 +11796,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7942,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +12156,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +500," Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +12201,Is it BNP or BMP?,19 +5974,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid care to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +7429,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +1796," A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",29 +841," The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",24 +12373,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6803,"9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.",20 +9403,A 23-year-old white female presents with complaint of allergies.,0 +2003, Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.,27 +4114,"This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.",39 +1658, A 9-month well-child check.,29 +11782,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +9004,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +4523,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4004,This is a middle-aged female with two month history of low back ache and leg pain.,22 +1361, Emergency cesarean section.,38 +4635,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +7056,"Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.",26 +3160," 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.",27 +3130," Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.",38 +4588,"Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.",28 +5976,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",26 +5049,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.,24 +12380,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7250,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +12343,Work restrictions and disability evaluation,4 +3912, Lumbar puncture with moderate sedation.,23 +5310,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 +3631," The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.",14 +3661, Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.,33 +1292," Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +2663," Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.",3 +5236,Single frontal view of the chest. Respiratory distress. The case has a history of malrotation.,29 +10137,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +2863, Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 +1718, Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,38 +7598,Mother states he has been wheezing and coughing.,0 +1639, The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,5 +7700,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +210," Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.",14 +8825,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +1682, The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation.,3 +38, Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,38 +7777,An example/template for a routine normal male physical exam.,25 +9468,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9099,Preop evaluation regarding gastric bypass surgery.,2 +9461,Mother states he has been wheezing and coughing.,0 +8908,"Followup diabetes mellitus, type 1.",13 +9194,Consultation for wrist pain.,4 +1949," C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.",27 +12111,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6953,Initial evaulation - neck and back pain.,4 +5450,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,16 +8024,MRI report Cervical Spine (Chiropractic Specific),4 +5890,Pain and swelling in the right foot.,31 +2761, Cause of death - Anoxic Encephalopathy,1 +4109,Patient with a history of ischemic cardiac disease and hypercholesterolemia.,35 +11982,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +2995," CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).",33 +4877,Incision and drainage (I&D) of buttock abscess.,8 +3620, Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,23 +8851,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +4792,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +5648,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",31 +7436,Mother states he has been wheezing and coughing.,0 +4477,Left temporal craniotomy and removal of brain tumor.,22 +11170,Work restrictions and disability evaluation,4 +8328,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +5754,Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 +6203,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +3524," Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.",39 +4506,"Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",26 +53, Patient with a history of ischemic cardiac disease and hypercholesterolemia.,35 +1253," A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",5 +4048,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 +326," Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.",27 +11419,Autopsy of a white female who died of acute combined drug intoxication.,1 +10035,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +3172, MRI cervical spine.,27 +2862, The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,10 +7574,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5657,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 +5078,Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular discomfort status post CT scan of the thorax.,16 +9735,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9474,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +1588, Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 +1265," Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants. Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.",24 +10287,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +11168,Work restrictions and disability evaluation,4 +3658," Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",24 +5654,"Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",26 +2866," Phacoemulsification of cataract and posterior chamber lens implant, right eye.",38 +5407,"Skull, complete, five images.",29 +5062,"This is a 53-year-old man, who presented to emergency room with multiple complaints including discomfort from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.",12 +8634,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +482, Patient with a long history of depression and attention deficits.,32 +10859,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7484,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5972,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid care to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +12166,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11707,Autopsy - Homicide - Blunt force cranial trauma,1 +52," Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm",3 +4776,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +6076,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +8434,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3855," Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",3 +12507,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6947,Caudal epidural steroid injection,28 +682," Fiberoptic nasolaryngoscopy. Dysphagia with no signs of piriform sinus pooling or aspiration. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.",38 +8157,Evaluation for chronic ache program,4 +12036,MRI report Cervical Spine (Chiropractic Specific),4 +11528,Patient presents for therapy of suspected rheumatoid arthritis.,34 +1071," 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. ",25 +1801," Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years. ",38 +5245,Death summary of client with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,10 +8177,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +283," Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.",38 +8137,Consult for laparoscopic gastric bypass.,2 +9663,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5227,"Head injury, anxiety, and hypertensive emergency.",29 +358, Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.,22 +6583,Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.,23 +8584,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +2743, Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,33 +3287, Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,39 +3984," Patient with a history of gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.",5 +6706,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +11630,Dietary consultation for gestational diabetes.,9 +8803,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +8414,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2263, Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. ,14 +8384,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +10202,A sample note on Rheumatoid Arthritis,34 +10054,Work restrictions and disability evaluation,18 +3800, Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.,33 +1256, Trauma/ATV accident resulting in left open humerus fracture.,10 +7892,Hand dermatitis.,8 +8724,Work restrictions and disability evaluation,18 +5883,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +2937, A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath.,5 +2247," Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",27 +6436,"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and care planning.",32 +5776,The client was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.,32 +11644,Dietary consultation for diabetes during pregnancy.,9 +5852,"Toenails are discolored, thickened, and painful - Onychomycosis",31 +1603," Right hand laceration x3, repaired.",25 +8967,Mother states he has been wheezing and coughing.,0 +1548," Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.",38 +11306,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +3600," MRI of the Cervical, Thoracic, and Lumbar Spine",22 +4082,"Pressure decubitus, right hip",15 +6540,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",32 +7697,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +1649," Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.",38 +2881, Excisional biopsy of right cervical lymph node.,16 +4215,"2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",15 +8224,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11366,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11930,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +7639,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5773,"Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +8051,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +57," Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",27 +10094,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +3090," Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.",14 +10712,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8581,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6346,"Visually significant cataract, left eye. Phacoemulsification cataract extraction with intraocular lens implantation, left eye. The case 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.",26 +9877,Dietary consultation for diabetes during pregnancy.,9 +9278,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +6443,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.,16 +9513,Autopsy of a white female who died of acute combined drug intoxication.,1 +3447, A female for a complete physical and follow up on asthma with allergic rhinitis.,15 +10334,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +2853," Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",21 +3346," Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. ",12 +9175,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +8310,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +12184,A 23-year-old white female presents with complaint of allergies.,0 +483," A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. ",5 +7788,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +11955,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +7021,An example/template for a routine normal female physical exam.,25 +321," Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. +",3 +5297,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",10 +7897,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +3566," Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.",38 +6127,Trabeculectomy with mitomycin C - Sample/Template.,26 +11084,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12102,Autopsy - Asphyxia due to ligature strangulation.,1 +8451,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +12470,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1272," EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. ",38 +5499,"Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 +5522,Patient referred for narrow angles and possible associated glaucoma.,20 +7342,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10864,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +9450,"Specimen labeled ""sesamoid bone left foot"".",19 +11451,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +542," Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",39 +2205," Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 +10728,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +2693," Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +3644," Hematemesis in a patient with longstanding diabetes. Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis. Mallory-Weiss tear, successful BICAP cautery. ",14 +12130,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1212, Hand dermatitis.,8 +11088,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12488,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2975," Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.",38 +8283,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +11018,Is it BNP or BMP?,19 +6782,Blepharoplasty with direct brow repair.,26 +12033,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +10327,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +3999,"Bilateral Mammogram, (abnormal) additional views requested",33 +3318," Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.",5 +8499,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2228, MRI Head W&WO Contrast.,22 +11777,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3026, Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 +9223,Cause of death - Anoxic Encephalopathy,1 +8221,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +6616,Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 +12223,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +1556," Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.",24 +3489, The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,35 +1372," Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +3058, Blood in urine - Transitional cell cancer of the bladder.,39 +9700,A sample note on Rheumatoid Arthritis,34 +11596,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +10759,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7320,A sample note on Rheumatoid Arthritis,34 +1115, 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. ,38 +3924, Esophagogastroduodenoscopy and colonoscopy with polypectomy,38 +12421,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6934,CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 +6564,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +12289,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8370,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +12008,"Followup diabetes mellitus, type 1.",13 +10281,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +11685,Mother states he has been wheezing and coughing.,0 +6348,"Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The client was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 +2964, Psychiatric consultation for alcohol withdrawal and dependance.,32 +4203,Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 +3071, The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. ,5 +199," Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.",38 +7496,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +6880,Bilateral lumbar sympathetic block. The client was in the prone position and the back prepped with Betadine. The client was given sedation and monitored.,28 +5665,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 +740, Acute appendicitis and 29-week pregnancy. Appendectomy.,38 +11375,A sample note on Rheumatoid Arthritis,34 +239, Bilateral renal ultrasound.,33 +2392, Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.,38 +2227, Right pleural effusion and suspected malignant mesothelioma.,16 +11237,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +10408,Dietary consultation for carbohydrate counting for type I diabetes.,9 +8269,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +8271,Incision and drainage of right buccal space abscess and teeth extraction.,7 +4699,A 34-year old female with no fetal heart motion noted on office scan.,24 +5981,Patient has prostate cancer with metastatic disease to his bladder. The case has had problems with hematuria in the past. The case was encouraged to drink extra water and was given discharge instructions on hematuria.,12 +4065,HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 +4935,Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 +5554,"Sample normal ear, nose, mouth, and throat exam.",11 +2534, Punch biopsy of right upper chest skin lesion.,8 +4060,Foul-smelling urine and stomach ache after meals.,14 +11988,Occupational medicine consult with questions-answers and records review.,18 +1046, Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.,3 +5642,"Re-excision of squamous cell carcinoma site, right hand.",16 +12610,A sample note on Rheumatoid Arthritis,34 +12531,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7591,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +752," Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",38 +2641, NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.,27 +7909,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +1572," Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.",23 +12212,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2747, Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 +10768,Autopsy - Homicide - Blunt force cranial trauma,1 +10542,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1902, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,38 +5017,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",35 +5856,Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.,26 +1952," He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.",35 +1790," The patient with gradual onset of a headache problem, located behind both eyes.",5 +4381,"Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant discomfort requiring surgical evaluation. It did not appear that the discomfort was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",24 +631," Right inguinal hernia. Right inguinal hernia repair. The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 +2677," Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",38 +11126,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8043,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +12485,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +2826, Congestive heart failure (CHF) with left pleural effusion. Anemia of chronic disease.,10 +9352,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11980,Is it BNP or BMP?,19 +8746,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +3582, A 66-year-old female with knee osteoarthrosis who failed conservative management.,10 +2565, Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy. ,11 +4406,"Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.",33 +6833,"The client is a 26-year-old female, referred to Physical Therapy for low back pain. The client has a history of traumatic injury to low back.",30 +8860,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8847,Dietary consultation for diabetes during pregnancy.,9 +3870, A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +2533," VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.",3 +850, Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.,14 +7307,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4957,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +11483,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +10302,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +8303,Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +403, The patient is brought in by an assistant with some of his food diary sheets.,5 +1771," Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.",38 +8210,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +7031,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +917," Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. ",27 +10049,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +229," Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",22 +10162,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +6358,"Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 +3322, 2-D Echocardiogram,33 +10656,A 23-year-old white female presents with complaint of allergies.,0 +8829,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +8823,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +2814, Initial clinic visit for foreign body in left eye.,15 +8910,"Followup diabetes mellitus, type 1.",13 +12544,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2100, Right ear pain with drainage - otitis media and otorrhea.,11 +8591,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +5721,Transnasal transsphenoidal approach in resection of pituitary tumor. The case is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,23 +2541, 13 years old complaining about severe ear pain - Chronic otitis media.,29 +7125,The client was referred due to a recent admission for pseudoseizures.,32 +5064,Ophthalmology followup visit note.,26 +11723,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +1217, Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. ,38 +3075," Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.",5 +1671," Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. ",24 +9248,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2187, Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally.,38 +7798,Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 +12189,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2292, Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 +7453,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +9054,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +2225, Problem of essential hypertension. Symptoms that suggested intracranial pathology.,35 +4911,The case returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,39 +11117,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8272,Incision and drainage of right buccal space abscess and teeth extraction.,7 +2978," Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +145," Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",5 +11267,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +1252," The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",26 +4220,External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 +1406," The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. ",5 +12169,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4999,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +11622,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11780,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4663,"Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",26 +4691,Patient with a long history of depression and attention deficits.,32 +7089,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +456," Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",5 +3049, Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.,39 +6965,"Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +12126,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2065, MRI left knee without contrast.,33 +5073,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +12201,Is it BNP or BMP?,19 +5878,Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 +12401,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +4622,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +448, Resting Myoview and adenosine Myoview SPECT,3 +8785,Is it BNP or BMP?,19 +8108,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +4459,Sample Radiology report of knee (growth arrest lines).,33 +5055,"Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 +6162,Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated.,28 +1311," Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",14 +6574,Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,23 +6328,Scleral Buckle opening under general anesthesia.,26 +4616,Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,11 +1594," Sample normal ear, nose, mouth, and throat exam.",15 +196, Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.,5 +11276,Evaluation for bariatric surgery.,2 +3820, Patient was found to have decrease in mental alertness,5 +5189,"Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",24 +8162,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10956,Patient presents for care of suspected rheumatoid arthritis.,34 +8974,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +5009,"The client is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",11 +1315, Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,14 +11067,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11931,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +10911,Dietary consultation for carbohydrate counting for type I diabetes.,9 +1231, Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.,33 +12282,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +58," Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 +1478," BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.",24 +5558,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +7890,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +3054," Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.",14 +6808,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 +2525, A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,33 +3365," Sample normal ear, nose, mouth, and throat exam.",25 +5331,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +7520,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +174," The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 +668, Patient with complaint of dark urine and generalized weakness.,5 +2474," Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.",15 +9022,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +4058,"Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 +7643,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +376," Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 +9161,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +11282,Occupational medicine consult with questions-answers.,18 +9389,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10968,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3730," Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ",3 +9790,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2468," Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. ",3 +12281,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5915,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +9992,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +8422,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +9784,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1755," Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ",38 +5223,"Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",24 +12225,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5134,The case is being referred for evaluation of diabetic retinopathy.,20 +4576,Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.,29 +4875,Incision and drainage (I&D) of buttock abscess.,8 +9051,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +9049,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11082,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +601," Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.",24 +752," Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",38 +12633,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12644,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2484, Repair of ruptured globe involving posterior sclera - Sample/Template. ,26 +1440, The patient is being discharged for continued hemodialysis and rehab.,21 +12559,A 23-year-old white female presents with complaint of allergies.,0 +7003,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +10273,"The client complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +12159,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6668,Sepsis. The case was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,16 +11180,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +74," A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ",5 +8171,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +2305, GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia.,14 +7551,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3677, The patient had a syncopal episode last night. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations.,5 +7328,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9163,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +11765,Cause of death - Anoxic Encephalopathy,1 +6842,Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.,29 +764, A two week well-child check.,29 +9483,Autopsy - Homicide - Blunt force cranial trauma,1 +12422,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8904,"Followup diabetes mellitus, type 1.",13 +4427,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,33 +8181,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +2333," Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes.",5 +11939,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +1789," 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.",38 +8562,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +4688,1-month-old for a healthy checkup - Well child check,29 +5589,"Patient with a identification of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",21 +12059,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +4891,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,35 +5617,Normal vasectomy,39 +12556,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6454,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +308, Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +9547,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1181, Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,38 +12237,Mother states he has been wheezing and coughing.,0 +8780,Dietary consultation for gestational diabetes.,9 +7283,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12401,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +4770,Polycythemia rubra vera. The case is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 +9177,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +944, a pleasant 62-year-old male with cerebral palsy,10 +10771,A sample note on Rheumatoid Arthritis,34 +9800,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9418,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +10808,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +12279,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +4687,1-month-old for a healthy checkup - Well child check,29 +73, Direct laryngoscopy and esophagoscopy with removal of foreign body,38 +430, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,38 +4503,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +361, Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,38 +12094,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3631," The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.",14 +3627, Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +10769,Autopsy - Homicide - Blunt force cranial trauma,1 +5300,Fifth disease with sinusitis,35 +7237,Mother states he has been wheezing and coughing.,0 +897, MRI left knee.,33 +9216,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +1189, A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,35 +6427,"The case is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.",29 +4834,"Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 +6700,"The case is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",29 +3963, Discharge summary of a patient with mood swings and oppositional and defiant behavior.,10 +3788," Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ",38 +11685,Mother states he has been wheezing and coughing.,0 +8219,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +10151,"Specimen labeled ""sesamoid bone left foot"".",19 +1348," Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.",35 +3246," Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",39 +6350,"Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The case was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 +6670,Psychiatric consultation for alcohol withdrawal and dependance.,32 +11188,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11827,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9717,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +793," Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.",14 +8505,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10375,"The case with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +2991," The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.",29 +10308,Consult for laparoscopic gastric bypass.,2 +4984,Patient with fever of unknown origin.,10 +12255,A sample note on Rheumatoid Arthritis,34 +11129,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10786,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +11957,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +3968, Well-child check and school physical.,29 +10654,A 23-year-old white female presents with complaint of allergies.,0 +9378,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +12592,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6252,Status post cadaveric kidney transplant with stable function.,21 +7045,Nephrology office visit for followup of microscopic hematuria.,25 +12527,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8497,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +1353," Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management",5 +7740,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +9785,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4372,Most commonly used phrases in physical exam.,25 +5259,"This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +5892,Autopsy - Homicide - Blunt force cranial trauma,1 +3664, Lumbar puncture with moderate sedation.,38 +11576,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +12309,Patient presents for care of suspected rheumatoid arthritis.,34 +4547,"Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",26 +2833, The patient with continued problems with her headaches. ,22 +7692,Procedure note on Keller Bunionectomy,31 +10798,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +10949,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7429,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +10084,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +6133,Parotidectomy procedure,11 +9926,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +1088, Psychiatric Consultation of patient with dementia.,32 +12086,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +5275,Pediatric Gastroenterology - Rectal Bleeding Consult.,29 +61," The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +2851, Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +190," A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.",5 +6046,Letter to the client to let him know about his abnormal cholesterol test results.,20 +5967,Laparoscopic right partial nephrectomy due to right renal mass.,21 +5002,Vaginal discharge with a foul odor.,24 +9659,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7884,Occupational medicine consult with questions-answers and records review.,18 +2656," Normal physical exam template. Well developed, well nourished, in no acute distress.",15 +5288,"Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.",24 +2339, Flexible bronchoscopy to evaluate the airway (chronic wheezing).,38 +10221,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +5481,"Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",12 +11899,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +11802,Autopsy - Asphyxia due to ligature strangulation.,1 +2923," First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",5 +2393," Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +6131,Parotidectomy procedure,11 +7501,Autopsy - Asphyxia due to ligature strangulation.,1 +399," Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.",38 +10512,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +1807," C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.",38 +6558,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +2830, Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,33 +3158," Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",38 +9196,Consultation for wrist pain.,4 +286, Sample Radiology report of knee (growth arrest lines).,33 +10101,Dietary consultation for diabetes during pregnancy.,9 +9361,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +329," Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.",26 +1459, Right carpal tunnel syndrome. Right carpal tunnel release.,27 +6596,Noncontrast CT abdomen and pelvis per renal stone protocol.,21 +2110, A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,3 +5925,"An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",12 +5732,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +1093," Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.",38 +3426, Bilateral myringotomy tubes and adenoidectomy.,11 +10907,Dietary consultation for carbohydrate counting for type I diabetes.,9 +10131,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +8598,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +2297, Autopsy of a white female who died of acute combined drug intoxication.,1 +3648," The patient is 14 months old, comes in with a chief complaint of difficulty breathing. ",3 +7948,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +11772,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12527,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4059,Foul-smelling urine and stomach ache after meals.,14 +6004,The client presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,12 +644," Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.",3 +7752,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.",30 +4266,The case comes in today because of feeling lightheaded and difficulty keeping his balance.,22 +9900,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +6560,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +11692,Mother states he has been wheezing and coughing.,0 +5681,Patient being referred for evaluation of glaucoma.,26 +7999,Autopsy - Homicide - Blunt force cranial trauma,1 +5574,An example/template for a routine normal female physical exam.,25 +916," Arthroscopy with arthroscopic subacromial decompression of the left shoulder. Impingement syndrome, left shoulder. Rule out superior labrum anterior and posterior lesion, left shoulder.",38 +11831,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10152,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +9571,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6929,"Sample normal ear, nose, mouth, and throat exam.",25 +12515,Patient presents for care of suspected rheumatoid arthritis.,34 +1443," Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.",38 +6351,"Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +725," MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.",27 +1244, MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.,22 +884, Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,27 +5306,Stage I and II neuromodulator.,39 +8670,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +12334,A sample note on Rheumatoid Arthritis,34 +9461,Mother states he has been wheezing and coughing.,0 +5209,Occupational medicine consult with questions-answers.,18 +11341,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +8170,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +2724," Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy. Colon cancer screening. Family history of colon polyps.",14 +11837,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6783,MRI right ankle.,31 +421, Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,38 +8589,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +6052,"Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",26 +5929,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,12 +11734,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +10294,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +4633,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +9871,Dietary consultation for diabetes during pregnancy.,9 +3080," A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the diagnosis of intracranial bleeding.",12 +6458,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +7013,Dietary consultation for carbohydrate counting for type I diabetes.,9 +3832, Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.,3 +6721,Left temporal craniotomy and removal of brain tumor.,23 +6216,"The client is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 +352," Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures, ",38 +10977,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8490,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +2557, Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.,14 +11664,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +2301," Patient with chest pains, CAD, and cardiomyopathy.",3 +11311,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +1165," The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.",12 +7488,Dietary consultation for carbohydrate counting for type I diabetes.,9 +7565,A 23-year-old white female presents with complaint of allergies.,0 +8718,A 23-year-old white female presents with complaint of allergies.,0 +8610,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +4630,Patient with immune thrombocytopenia,16 +455," Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",26 +7962,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +5922,Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 +8191,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +10069,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +6893,Osteoarthritis of the right knee. Right knee joint steroid injection.,28 +10184,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +9343,Patient presents for care of suspected rheumatoid arthritis.,34 +12139,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6606,"Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",21 +1629, The patient is status post C3-C4 anterior cervical discectomy and fusion.,33 +11404,Preop evaluation regarding gastric bypass surgery.,2 +10539,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +4981,A two week well-child check.,29 +10117,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +783," Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.",5 +6130,A 66-year-old client who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 +5854,"Toenails are discolored, thickened, and painful - Onychomycosis",31 +6963,Bilateral myringotomy tubes and adenoidectomy.,11 +1139, Fifth disease with sinusitis,15 +4421,Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 +5577,Endoscopic proximal shunt revision.,23 +588, The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.,14 +10169,Chiropractic IME with answers to questions from Insurance Company.,18 +11133,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11154,A sample note on Rheumatoid Arthritis,34 +2586, Full mouth dental rehabilitation in the operative room under general anesthesia.,38 +2059," Laparoscopy with ablation of endometriosis. Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.",38 +10789,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +9586,Autopsy - Asphyxia due to ligature strangulation.,1 +12637,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11475,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +3067, Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,14 +8617,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +7783,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +6642,"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +7411,Dietary consultation for gestational diabetes.,9 +7422,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +459," Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.",38 +673, Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11831,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10439,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +151, Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,14 +11849,A sample note on Rheumatoid Arthritis,34 +5838,Patient complains of constipation. Has not had BM for two days.,25 +9924,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +4499,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +2053," Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +734, Bilateral carotid ultrasound to evaluate pain.,33 +7190,Patient presents for care of suspected rheumatoid arthritis.,34 +9480,Autopsy - Homicide - Blunt force cranial trauma,1 +2578, Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.,15 +6660,"Discharge summary of client with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",16 +12655,Patient presents for care of suspected rheumatoid arthritis.,34 +314," Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. ",24 +8727,Work restrictions and disability evaluation,18 +672," Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",21 +6431,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 +9549,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4707,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +657," Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.",5 +11665,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +1080, Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.,38 +11421,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +1128, Fractional dilatation and curettage,24 +9753,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7213,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +5666,"Specimen labeled ""sesamoid bone left foot"".",19 +7293,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +156, Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,21 +6986,"Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",31 +10237,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +131," A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.",3 +3011," Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.",38 +12516,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11532,Work restrictions and disability evaluation,4 +12222,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +4495,Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 +6478,Evaluation for chronic discomfort program,4 +11475,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +8453,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11619,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2571," Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",24 +10746,Mother states he has been wheezing and coughing.,0 +1163," Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",14 +3533, A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. ,3 +3402, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,38 +2791," Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",5 +4512,"Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the case has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.",24 +11819,Patient presents for care of suspected rheumatoid arthritis.,34 +9719,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +10137,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +6465,"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.",26 +12579,Is it BNP or BMP?,19 +7978,Mother states he has been wheezing and coughing.,0 +9832,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +951," Capsulotomy left breast and flat advancement V to Y, left breast, for correction of lower pole defect (breast assymetry) status post previous breast surgery.",38 +10097,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +3884," A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",22 +8243,"Synovitis - anterior cruciate ligament tear of the left knee. The client is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The client fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +5592,Psychiatric History and Physical - Patient with schizoaffective disorder.,32 +2519," Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",16 +1454, The patient admitted with palpitations and presyncope.,5 +7282,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6519,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +616, Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,38 +7443,A sample note on Rheumatoid Arthritis,34 +6027,"Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 +876, A 23-year-old white female presents with complaint of allergies.,0 +11058,A sample note on Rheumatoid Arthritis,34 +4850,Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.,24 +2863, Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 +4682,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,22 +9417,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8866,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9545,Cause of death - Anoxic Encephalopathy,1 +11076,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2624, Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.,24 +6991,"Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",21 +9213,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +12315,Patient presents for therapy of suspected rheumatoid arthritis.,34 +10204,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +1211, Bilateral myringotomies with insertion of Santa Barbara T-tube.,38 +4182,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 +9023,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +7154,Patient dropped a weight on the dorsal aspects of his feet.,12 +5562,A lady was admitted to the hospital with chest ache and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,10 +3813," Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. ",15 +11725,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +516," Nuclear medicine tumor localization, whole body - status post subtotal thyroidectomy for thyroid carcinoma.",33 +10710,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4781,The case was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.,35 +400," Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.",33 +8776,Dietary consultation for gestational diabetes.,9 +10873,Cause of death - Anoxic Encephalopathy,1 +5736,"Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate. Nasal septal deviation with bilateral inferior turbinate hypertrophy. Tonsillitis with hypertrophy. Edema to the uvula and soft palate.",11 +5341,Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,23 +2138, A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,12 +5610,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.,12 +5150,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +12143,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +185," Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",38 +12621,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11473,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +10866,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11716,A sample note on Rheumatoid Arthritis,34 +9821,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10193,Autopsy - Homicide - Blunt force cranial trauma,1 +4617,Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,11 +4036,"Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.",24 +8120,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +1541, Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.,38 +9559,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +321," Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. +",3 +9769,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12451,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +2831, Chest CT - Thymoma and history of ocular myasthenia gravis.,22 +2994," Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",38 +12093,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3808, The patient was referred due to a recent admission for pseudoseizures.,32 +7737,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +202," Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. ",22 +3538, Patient with increased shortness of breath of one day duration.,10 +5261,"This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +10259,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +342, Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.,27 +3444," 5-month recheck on type II diabetes mellitus, as well as hypertension.",35 +10963,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10074,Dietary consultation for gestational diabetes.,9 +5686,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +5848,"Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.",11 +4561,Falls at home. Anxiety and depression. The case had been increasingly anxious and freely admitted that she was depressed at home.,22 +1792, Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.,14 +11050,Autopsy - Homicide - Blunt force cranial trauma,1 +3405," Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.",33 +11427,Occupational medicine consult with questions-answers and records review.,18 +4057,"Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 +6277,"Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",31 +12299,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +657," Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.",5 +4996,"Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",21 +9825,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4263,A 65-year-old man with chronic prostatitis returns for recheck.,35 +10248,Significant ache in left lower jaw.,7 +11729,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5244,Death summary of client with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,10 +12509,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3111, Questionable need for antibiotic therapy for possible lower extremity cellulitis.,15 +2702, Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,38 +409," Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..",7 +1731," Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.",3 +5601,Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The case is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.,29 +8198,"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The case fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.",7 +2441," Removal of infected sebaceous cyst, right neck.",38 +5256,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.,23 +8979,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +5321,"A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.",29 +733, OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.,33 +4677,"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 +4496,Right distal ureteral calculus. The client had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.,39 +12230,Mother states he has been wheezing and coughing.,0 +1508, Left lower extremity venous Doppler ultrasound,33 +6658,Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 +9819,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +12433,Mother states he has been wheezing and coughing.,0 +3997, Repair of bilateral cleft of the palate with vomer flaps.,11 +1984, Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. ,26 +8139,Patient today with ongoing issues with diabetic control.,13 +1184, Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,35 +6536,"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.",21 +1641, Total colonoscopy with biopsy and snare polypectomy.,38 +1102, A 3-year-old abrupt onset of cough and increased work of breathing.,3 +5518,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +9034,MRI report Cervical Spine (Chiropractic Specific),4 +7774,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +5434,"Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.",28 +3530," GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.",5 +4570,"Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck ache",35 +8937,Chiropractic IME with answers to questions from Insurance Company.,18 +3282, Occupational medicine consult with questions-answers and records review.,5 +7145,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +5124,Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,23 +9101,Preop evaluation regarding gastric bypass surgery.,2 +8592,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +536, Polycythemia rubra vera. The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 +1522," Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week",5 +51," Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.",38 +9243,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9535,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +2226, Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.,27 +10705,Dietary consultation for diabetes during pregnancy.,9 +5382,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +3509, Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor. ,38 +4362,Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 +8784,Is it BNP or BMP?,19 +1996," Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 +3037, Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,38 +1295," Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. ",5 +932," Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. ",38 +11611,A 23-year-old white female presents with complaint of allergies.,0 +3946," Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.",16 +10764,Autopsy - Homicide - Blunt force cranial trauma,1 +2092, Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.,27 +2810," Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.",39 +11838,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9663,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3040, Epididymectomy,38 +830," Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI.",3 +2002," Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.",38 +7364,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10125,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +5077,Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular discomfort status post CT scan of the thorax.,16 +9227,Cause of death - Anoxic Encephalopathy,1 +5437,Psychiatric consultation for management of ache medications.,32 +7975,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +1870, Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. ,12 +1118," Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",27 +231, A 16-year-old male with Q-fever endocarditis.,3 +747, Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,38 +9718,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +5860,Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 +6711,Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,23 +4924,"Follow up consultation, second opinion, foreskin.",39 +11918,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3512, Bilateral myringotomy tubes and adenoidectomy.,38 +11952,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +7191,Patient presents for therapy of suspected rheumatoid arthritis.,34 +12376,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +6063,"C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",23 +7055,"Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.",26 +12575,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9406,A 23-year-old white female presents with complaint of allergies.,0 +11294,Is it BNP or BMP?,19 +1258," Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.",27 +5367,Fractional dilatation and curettage,24 +8710,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +4069,Normal Circumcision,39 +7161,Qualified healthcare evaluation report of a patient with back pain.,4 +5193,Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.,24 +3165," History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound.",27 +9641,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11575,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7163,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent healthcare evaluation.,18 +5032,"Plantar fascitis, left foot. Partial plantar fasciotomy.",31 +9127,Consult for laparoscopic gastric bypass.,2 +4962,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +8209,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +12363,Occupational medicine consult with questions-answers and records review.,18 +6057,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,25 +9546,Cause of death - Anoxic Encephalopathy,1 +9133,Autopsy of a white female who died of acute combined drug intoxication.,1 +11870,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7489,Dietary consultation for carbohydrate counting for type I diabetes.,9 +7219,A 23-year-old white female presents with complaint of allergies.,0 +1803, Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,38 +3463, Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.,33 +7800,Incision and drainage (I&D) of buttock abscess.,8 +5909,The case underwent an overnight polysomnogram.,36 +1662, Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,22 +4548,"Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",26 +11996,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +12366,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +9151,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +8680,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +5232,"Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",28 +2650, Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +423," Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.",3 +12442,A sample note on Rheumatoid Arthritis,34 +8656,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +12051,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +1934, 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias.,38 +6704,Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 +8357,Back injury with RLE radicular symptoms. The client is a 52-year-old male who is here for independent medical evaluation.,18 +8882,"Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +12133,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12588,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +12581,Is it BNP or BMP?,19 +8654,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +149, Patient with palpitations and rcent worsening of chronic chest discomfort.,5 +195," Nausea, vomiting, diarrhea, and fever.",5 +5254,"Clogged AV shunt. The client complains of fatigue, nausea, vomiting and fever.",21 +11661,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9154,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +10233,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +7666,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +7764,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +3588," Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.",11 +4069,Normal Circumcision,39 +2278," Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.",27 +11436,Completion thyroidectomy with limited right paratracheal node dissection.,13 +6280,"Acute foot or ankle sprain, possible small fracture.",31 +4457,Sample Radiology report of knee (growth arrest lines).,33 +10214,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +1926," Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",10 +7314,A sample note on Rheumatoid Arthritis,34 +3908, Elevated cholesterol and is on medication to lower it.,5 +11537,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2360, Occupational medicine consult with questions-answers and records review.,18 +8480,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +4943,"Counting calorie points, exercising pretty regularly, seems to be doing well",35 +3331, Plantar Fascia Injection,28 +10028,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +3528," A 44-year-old, 250-pound male presents with extreme pain in his left heel.",31 +3865," CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",33 +9366,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8375,Patient presents for therapy of suspected rheumatoid arthritis.,34 +3866, Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,3 +12116,Patient presents for therapy of suspected rheumatoid arthritis.,34 +3605, 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.,3 +5376,Difficulty with both distance vision and with fine print at near.,26 +11482,"The case with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +5253,"Clogged AV shunt. The client complains of fatigue, nausea, vomiting and fever.",21 +1354," Sample normal ear, nose, mouth, and throat exam.",11 +9481,Autopsy - Homicide - Blunt force cranial trauma,1 +107, Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia.,38 +7794,Chiropractic IME with answers to questions from Insurance Company.,4 +906," Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.",27 +2673, CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,14 +7908,Followup of moderate-to-severe sleep apnea. The client returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +11189,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +9533,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4043,Common description of colonoscopy,14 +3937, AP abdomen and ultrasound of kidney.,33 +1699, Thoracentesis. Left pleural effusion. Left hemothorax.,3 +2618, Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,5 +5116,Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,32 +10565,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +6588,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 +6232,"Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 +10584,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +3406, The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.,5 +9558,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +9123,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +8062,Preop evaluation regarding gastric bypass surgery.,2 +11964,Work restrictions and disability evaluation,18 +9246,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10345,The client has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +2120, Ruptured globe with full-thickness corneal laceration repair - Sample/Template.,38 +9006,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +9235,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +9933,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +3720," Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +7251,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5811,Cadaveric renal transplant to right pelvis - endstage renal disease.,21 +506, This patient has reoccurring ingrown infected toenails.,31 +2553," Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.",27 +2300," Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.",38 +3617," Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.",3 +2292, Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 +10867,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8342,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +1969, Fertile male with completed family. Elective male sterilization via bilateral vasectomy.,39 +4644,"A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",29 +11917,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +9477,Autopsy - Homicide - Blunt force cranial trauma,1 +10048,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +9705,A sample note on Rheumatoid Arthritis,34 +5213,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +5588,"Patient with a identification of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.",21 +1111, MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,22 +11351,Chiropractic IME with answers to questions from Insurance Company.,18 +8182,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +9449,"Specimen labeled ""sesamoid bone left foot"".",19 +6977,Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 +1079," Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency",15 +2773, MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,27 +12459,Autopsy of a white female who died of acute combined drug intoxication.,1 +4729,A sample note on Cataract,26 +9568,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +5303,"Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",24 +7205,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5769,Blepharoplasty procedure,6 +5399,"The client is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.",12 +7896,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +1245, Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,27 +2061," BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.",33 +2452, Consultation for wrist pain.,27 +7728,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10428,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +3963, Discharge summary of a patient with mood swings and oppositional and defiant behavior.,10 +4911,The case returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,39 +5906,"Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",21 +9063,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +6890,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 +12091,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2103, A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 +7611,A sample note on Rheumatoid Arthritis,34 +3039, Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization.,38 +4053,Bilateral Myringotomy with placement of PE tubes,11 +9550,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12523,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9904,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +12352,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +6168,"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.",6 +10377,Patient scheduled for laparoscopic gastric bypass.,2 +703, Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,5 +10098,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7737,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +10703,Dietary consultation for diabetes during pregnancy.,9 +1679," The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. ",14 +11917,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +11976,Dietary consultation for gestational diabetes.,9 +373, Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,32 +12656,Patient presents for therapy of suspected rheumatoid arthritis.,34 +10991,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +619, Excision of penile skin bridges about 2 cm in size.,39 +2832, A 14-year-old young lady is in the renal failure and in need of dialysis.,38 +10500,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +4917,Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,24 +675," Patient with multiple problems, main one is chest pain at night.",15 +1929, Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.,12 +10243,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +8438,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +2294, Invasive carcinoma of left breast. Left modified radical mastectomy.,38 +2218," Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",11 +12384,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +2167," Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs",5 +11751,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7359,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +6492,Preoperative visit for weight management with laparoscopic gastric banding,2 +1344," Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",31 +395, Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.,14 +10718,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5477,Trauma/ATV accident resulting in left open humerus fracture.,10 +12310,Patient presents for care of suspected rheumatoid arthritis.,34 +6499,"CT abdomen and pelvis without contrast, stone protocol, reconstruction.",21 +7382,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2141," A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.",32 +11132,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3989, Common CT Facial template.,33 +10647,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +10232,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +7962,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +6074,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +5808,Bilateral sacroiliac joint injections,28 +6674,Sample/template for a normal female multisystem exam,25 +8288,Dietary consultation for carbohydrate counting for type I diabetes.,9 +11614,A 23-year-old white female presents with complaint of allergies.,0 +8478,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +227, Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.,27 +564, A middle-aged male with increasing memory loss and history of Lyme disease.,33 +6744,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 +3687," Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.",38 +10638,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +8774,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +11492,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +12372,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7676,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4232,Sample progress note - Gen Med.,15 +112," Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",38 +4648,CT Abdomen and Pelvis with contrast,21 +199," Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.",38 +7824,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +2257, An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,5 +1092," Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. ",27 +3283," Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,",27 +5377,Difficulty with both distance vision and with fine print at near.,26 +4142,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +2871," The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",35 +9466,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11203,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +7220,A 23-year-old white female presents with complaint of allergies.,0 +2533," VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.",3 +1789," 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.",38 +3465," Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. ",38 +3268," 11-year-old female. History of congestion, possibly enlarged adenoids. ",5 +6006,Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +11880,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12601,Autopsy - Homicide - Blunt force cranial trauma,1 +3455," Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical",5 +8372,Evaluation and recommendations regarding facial rhytids.,8 +10213,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +6561,Patient in ER complaining of shortness of breath (COPD),12 +5746,Mother states he has been wheezing and coughing.,29 +8244,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +7921,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +3700, Right foot series after a foot injury.,31 +317, A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,24 +9167,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +1717, Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +6644,"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +7270,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +9128,Consult for laparoscopic gastric bypass.,2 +63," Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12381,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +2628, Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. ,14 +6589,"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 +11723,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +3091, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,23 +6898,Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 +12419,Dietary consultation for diabetes during pregnancy.,9 +9883,Mother states he has been wheezing and coughing.,0 +4050,"Incision and drainage and removal of foreign body, right foot. The client has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +12009,"Followup diabetes mellitus, type 1.",13 +6106,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +12107,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +6549,"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.",16 +11108,Patient presents for care of suspected rheumatoid arthritis.,34 +3560, Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.,33 +12105,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +1795, Right undescended testicle. Orchiopexy & Herniorrhaphy.,39 +4378,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +8035,Letter to the client to let him know about his abnormal cholesterol test results.,20 +1404," Followup diabetes mellitus, type 1.",13 +6736,Patient scheduled for laparoscopic gastric bypass.,2 +12285,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4580,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,32 +10387,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +6715,Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 +10759,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11004,A 23-year-old white female presents with complaint of allergies.,0 +1773, Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,12 +7414,Is it BNP or BMP?,19 +2329, Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,5 +3803, Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.,39 +8904,"Followup diabetes mellitus, type 1.",13 +1596, Common CT C-Spine template,27 +5641,"Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",16 +1051," Pain and swelling in the right foot, peroneal tendon tear.",27 +9879,Mother states he has been wheezing and coughing.,0 +126," Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.",3 +10011,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6222,Admission Psychiatric Evaluation,32 +9788,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12197,Dietary consultation for gestational diabetes.,9 +8615,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +11539,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3330, Psychiatric History and Physical - Patient with major depression,5 +8958,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +6357,"Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",26 +11095,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3270, Antibiotic management for a right foot ulcer and possible osteomyelitis.,15 +7638,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10002,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +1529," Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ",22 +5768,Blepharoplasty procedure,6 +10219,Letter to the case to let him know about his abnormal cholesterol test results.,20 +4818,Chiropractic IME with answers to questions from Insurance Company.,4 +5268,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +1407, This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,27 +9186,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +9215,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11115,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9590,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1678, Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.,22 +8741,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7423,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +8316,Patient being referred for evaluation of glaucoma.,20 +7967,Chiropractic IME with answers to questions from Insurance Company.,18 +1312, MRI Brain and Brainstem - Falling (Multiple System Atrophy),22 +7733,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +10018,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +5841,"Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",23 +8533,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +5491,Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,26 +10482,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10385,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +5495,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +11298,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +11276,Evaluation for bariatric surgery.,2 +2266," Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.",38 +3141, 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. ,23 +2570, Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.,27 +7964,Blepharoplasty procedure,6 +12175,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7715,"Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +4040,Total colonoscopy with biopsy and snare polypectomy.,14 +7494,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +3783," Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",5 +5652,A white female with a history of fevers.,10 +538, The patient states that he feels sick and weak.,35 +7793,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +3549, A 60-year-old female presents today for care of painful calluses and benign lesions.,38 +6097,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +1855, Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 +11744,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +2214," Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.",14 +324," Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder. Partial rotator cuff tear with impingement syndrome. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.",38 +3304, Scleral Buckle opening under general anesthesia.,38 +5200,Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,24 +11463,Preoperative visit for weight management with laparoscopic gastric banding,2 +9328,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5291,"Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.",28 +3473," Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.",3 +2599, Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,10 +8552,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +5424,"Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to healthcare therapy, severe anemia, and fibroid uterus.",10 +4910,"Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",16 +6438,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,29 +5309,Is it BNP or BMP?,19 +4391,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",16 +8739,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7778,An example/template for a routine normal male physical exam.,25 +3600," MRI of the Cervical, Thoracic, and Lumbar Spine",22 +3035, Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 +5859,Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,23 +8993,Autopsy - Homicide - Blunt force cranial trauma,1 +8074,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +4612,"This is a 14-month-old baby boy Caucasian who came in with presumptive identification of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",10 +1611," Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.",33 +7690,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +6625,"Patient with a history of PTSD, depression, and substance abuse.",32 +7044,Nephrology office visit for followup of microscopic hematuria.,25 +12084,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6813,The client is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness.,11 +10166,Blepharoplasty procedure,6 +3399, A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,22 +6016,"Fever, otitis media, and possible sepsis.",11 +3673," Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.",23 +6395,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +7101,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +5663,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 +4722,Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 +1848, Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.,38 +10823,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +11352,Consultation for left foot pain.,4 +10285,Occupational medicine consult with questions-answers and records review.,18 +10910,Dietary consultation for carbohydrate counting for type I diabetes.,9 +2161," Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",27 +2974, Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.,14 +5339,Psychiatric Consultation of case with dementia.,32 +5644,"Re-excision of squamous cell carcinoma site, right hand.",16 +8753,Occupational medicine consult with questions-answers.,18 +12597,Mother states he has been wheezing and coughing.,0 +3883," Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",38 +553," Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.",15 +12039,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +6397,Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +7849,Work restrictions and disability evaluation,18 +6521,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +12240,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7980,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +1259, The patient was referred due to concerns regarding behavioral acting out as well as encopresis.,5 +10785,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +11922,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8364,Elevated cholesterol and is on medication to lower it.,9 +436, Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,5 +2899," Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain",15 +8998,Autopsy - Homicide - Blunt force cranial trauma,1 +6849,Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.,26 +6234,The case has a possibly torsion detorsion versus other acute testicular problem.,12 +8711,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +11671,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +1685," The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. ",3 +10353,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +1938, A 21-channel digital electroencephalogram was performed on a patient in the awake state.,36 +7162,Back injury with RLE radicular symptoms. The case is a 52-year-old male who is here for independent medical evaluation.,18 +7316,A sample note on Rheumatoid Arthritis,34 +6881,Bilateral lumbar sympathetic block. The case was in the prone position and the back prepped with Betadine. The case was given sedation and monitored.,28 +10984,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1180, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 +11781,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8717,A 23-year-old white female presents with complaint of allergies.,0 +476," Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.",5 +1687, A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. ,5 +4656,A 47-year-old female with a posttraumatic AV in the right femoral head.,10 +3315, Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. ,14 +11744,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +9296,Autopsy - Asphyxia due to ligature strangulation.,1 +6887,"Normal physical exam template. Well developed, well nourished, in no acute distress.",25 +12408,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +612, Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,14 +6145,"Normal physical exam template. Normocephalic. Negative lesions, negative masses.",25 +9826,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2613," Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.",38 +2704," Chest pain, Chest wall tenderness occurred with exercise.",33 +11253,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +4422,Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 +489, MRI of lumbar spine without contrast to evaluate chronic back pain.,27 +1567, Follicular non-Hodgkin's lymphoma. Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. Received six cycles of CHOP chemotherapy. ,16 +933," EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, ",33 +2768," Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.",38 +1338, Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,38 +1341, The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +5708,"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.",23 +1500," Specimen labeled ""sesamoid bone left foot"".",19 +11904,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10023,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +3281, Twin pregnancy with threatened preterm labor.,33 +8523,Chiropractic IME with answers to questions from Insurance Company.,20 +2638, Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema.,38 +4537,Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,14 +10810,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3606, Revision and in situ pinning of the right hip.,27 +3169," Lumbar epidural steroid injection, L5-S1. Low back pain.",28 +4676,"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 +3886, A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10404,Initial evaulation - neck and back pain.,4 +1921," Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.",38 +2817," T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",11 +11274,Evaluation for bariatric surgery.,2 +9178,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +5096,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",16 +11171,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +9017,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +4894,A sample note on bilateral myringotomy tubes,11 +9662,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2936," Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.",38 +12390,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +4579,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,32 +468," Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",10 +10098,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +6652,"Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum",11 +9899,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +9875,Dietary consultation for diabetes during pregnancy.,9 +11491,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +5173,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 +7629,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11649,Dietary consultation for diabetes during pregnancy.,9 +2843," Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ",7 +4191,"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +4857,Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The case was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,21 +2330," Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. ",5 +3135," The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.",15 +11394,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +11061,A sample note on Rheumatoid Arthritis,34 +12104,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +4358,"Open reduction, nasal fracture with nasal septoplasty.",11 +1942, Newborn circumcision. The penile foreskin was removed using Gomco. ,38 +8333,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +10901,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +8053,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +11935,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +9357,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2285, Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,3 +1222, A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,16 +3252, Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,38 +8302,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +5353,Patient in ER due to colostomy failure - bowel obstruction.,12 +7882,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +9880,Mother states he has been wheezing and coughing.,0 +6367,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +1062, Diagnostic cerebral angiogram and transcatheter infusion of papaverine,33 +56," Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.",38 +2652, Left distal medial hamstring release.,38 +5809,Bilateral sacroiliac joint injections,28 +9596,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3049, Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.,39 +3027, The patient presents for a followup for history of erythema nodosum.,5 +8389,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +12233,Mother states he has been wheezing and coughing.,0 +1087, Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,12 +11748,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +11693,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +625," Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",10 +11929,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +8582,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +1958, Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +7081,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +12545,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4487,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",22 +1971, Noncontrast CT abdomen and pelvis per renal stone protocol.,33 +4198,Diagnosis of benign rolandic epilepsy.,22 +11456,Evaluation for chronic discomfort program,4 +7611,A sample note on Rheumatoid Arthritis,34 +1374," Congestion, tactile temperature.",29 +12112,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5269,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +2309," Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",5 +8365,Elevated cholesterol and is on medication to lower it.,9 +3764, Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. ,16 +4718,This case has reoccurring ingrown infected toenails.,31 +8509,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +7557,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10309,Consult for laparoscopic gastric bypass.,2 +4774,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +10582,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +435," Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis. +",38 +4436,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",35 +2208, Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,38 +11604,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4028,"Laparoscopic tubal sterilization, tubal coagulation.",24 +7511,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +297, MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,33 +2467, The patient was admitted after undergoing a drawn out process with a small bowel obstruction.,10 +4520,Recurrent bladder tumor. The case on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,39 +9428,Is it BNP or BMP?,19 +8479,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +3708," Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.",27 +2919, Transplant nephrectomy after rejection of renal transplant,38 +7409,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4538,Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,23 +7946,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +10483,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10080,Is it BNP or BMP?,19 +2470, Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. ,3 +6592,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 +5824,Underwent tonsillectomy and adenoidectomy two weeks ago.,25 +6102,"Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +12657,Patient presents for therapy of suspected rheumatoid arthritis.,34 +10396,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +10719,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10040,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +762," Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.",3 +1870, Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. ,12 +11558,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5865,"Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 +10506,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +6399,Punch biopsy of right upper chest skin lesion.,8 +2011," Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.",38 +7485,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +6154,Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.,28 +697, Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps.,38 +10424,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +12183,A 23-year-old white female presents with complaint of allergies.,0 +894," Skull, complete, five images.",33 +6175,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +323, Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,39 +1994, Fall/loss of consciousness.,5 +8109,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +5428,The case was referred due to concerns regarding behavioral acting out as well as encopresis.,32 +8475,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +11808,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10254,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +10694,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +2955," A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.",3 +11672,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +12528,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +7103,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +2149," Normal physical exam template. Normocephalic. Negative lesions, negative masses.",25 +3106, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,32 +7441,Autopsy - Homicide - Blunt force cranial trauma,1 +6342,Standard hypogastric plexus block procedure note.,28 +2888, Patient in emergency room due to high potassium value.,15 +5417,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 +6760,"Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.",31 +334," Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",27 +10600,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +175, Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,11 +1156," Tonsillectomy and adenoidectomy. McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.",38 +5061,"This is a 53-year-old man, who presented to emergency room with multiple complaints including ache from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.",12 +208, Esophagogastroduodenoscopy performed in the emergency department.,14 +7100,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6066,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and discomfort to the left lower mandible area today.,7 +9340,Patient presents for care of suspected rheumatoid arthritis.,34 +10576,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2640, Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.,38 +1988, Costochondral Cartilage Injection,28 +12409,Dietary consultation for gestational diabetes.,9 +1271, Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,36 +10662,Evaluation for bariatric surgery.,2 +1582, Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 +8750,Occupational medicine consult with questions-answers.,18 +12583,Is it BNP or BMP?,19 +12241,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2856, Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,27 +4424,CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,11 +6179,"Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",21 +4395,Brain CT and MRI - suprasellar mass (pituitary adenoma),33 +8379,"Records review. The patient developed shooting discomfort about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +8921,"Specimen labeled ""sesamoid bone left foot"".",19 +10112,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +4883,"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.",39 +12431,"Specimen labeled ""sesamoid bone left foot"".",19 +4060,Foul-smelling urine and stomach ache after meals.,14 +3349, The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,5 +5646,"Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.",23 +11750,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6349,"Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The client was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 +2669," CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",21 +4478,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,33 +12123,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +12359,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +7130,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +9655,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9072,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +2103, A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 +9994,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +4297,"The case is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 +8551,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +10383,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +6523,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +10572,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +224, Dobutamine stress test for atrial fibrillation.,3 +6240,"Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",11 +6884,Psychological Testing for ADHD,32 +9321,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +5627,Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest ache,25 +7189,Patient presents for care of suspected rheumatoid arthritis.,34 +11165,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +10145,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +7963,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +12194,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5560,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +834," Positive peptic ulcer disease. Gastritis. Esophagogastroduodenoscopy with photography and biopsy. The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.",14 +12052,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +8069,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8144,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +4269,Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.,15 +5845,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +5318,"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.",25 +4283,Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,16 +8777,Dietary consultation for gestational diabetes.,9 +4669,"The client noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",39 +1469, The patient needs refills on her Xanax,15 +287, Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.,38 +8401,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6946,Caudal epidural steroid injection,28 +7466,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +8722,Work restrictions and disability evaluation,18 +2793, Patient presents for treatment of suspected rheumatoid arthritis.,5 +6458,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 +6322,Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 +11797,Autopsy - Asphyxia due to ligature strangulation.,1 +3123, Probable Coumadin hypersensitivity.,15 +11447,Encephalopathy related to normal-pressure hydrocephalus.,30 +3526, Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,22 +5217,"Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",21 +362, Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.,38 +2165, CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,33 +9580,Autopsy - Asphyxia due to ligature strangulation.,1 +1561, Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,38 +11225,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +7142,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 +957," Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.",38 +11635,Is it BNP or BMP?,19 +145," Chief complaint of chest pain, previously diagnosed with hyperthyroidism.",5 +10214,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +4710,Spermatocelectomy and orchidopexy,39 +12066,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +11857,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7549,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7648,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11258,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +11547,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8021,A 21-channel digital electroencephalogram was performed on a client in the awake state.,36 +1014, Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,10 +2397," Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",38 +2262," Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 +2815," A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.",38 +7379,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +10874,Cause of death - Anoxic Encephalopathy,1 +7070,"Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",29 +11028,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9983,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +4149,LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,24 +9381,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4821,"Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +306, Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 +10229,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +3505, Left breast cancer. Nuclear medicine lymphatic scan. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,33 +10478,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6090,Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +4292,"Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 +646, Esophagogastroduodenoscopy performed in the emergency department.,38 +158," The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",32 +11783,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +4243,"The client has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 +3823, Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition.,5 +1766, Left third digit numbness and wrist pain.,22 +11713,A sample note on Rheumatoid Arthritis,34 +2295," Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.",38 +1020," Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.",21 +3868," A woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia.",14 +1191, The patient was referred due to concerns regarding behavioral acting out as well as encopresis.,32 +9454,"Specimen labeled ""sesamoid bone left foot"".",19 +7792,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +759, Tracheotomy for patient with respiratory failure.,3 +10490,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3024, Patient with history of adenomas and irregular bowel habits.,38 +4179,Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,39 +10536,Occupational medicine consult with questions-answers and records review.,18 +5813,Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 +12593,Mother states he has been wheezing and coughing.,0 +8003,The client underwent an overnight polysomnogram.,36 +12338,A sample note on Rheumatoid Arthritis,34 +5423,"A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 +4992,"Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.",23 +10681,Dietary consultation for gestational diabetes.,9 +7259,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +8412,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3298," Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.",5 +1072, Chest tube talc pleurodesis of the right chest.,38 +5474,"The client with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",26 +726," Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",15 +5742,CT scan of the abdomen and pelvis without and with intravenous contrast.,21 +9316,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +9597,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4666,"Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.",16 +5265,"Excision of nasal tip basal carcinoma, previous positive biopsy.",16 +3194, Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,35 +318, Postpartum tubal ligation and removal of upper abdominal skin wall mass.,38 +4256,Urine leaked around the ostomy site for his right sided nephrostomy tube. The case had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,21 +11728,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9396,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +7832,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +4514,Psychiatric evaluation for major depression without psychotic features.,32 +9782,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +5762,Consultation for evaluation of thrombocytopenia.,16 +10762,Autopsy - Homicide - Blunt force cranial trauma,1 +7102,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6790,"Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 +10251,"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.",6 +2920," A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ",39 +5011,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",29 +2116," Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.",15 +11347,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +2393," Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +5447,Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 +12303,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8828,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +8390,Work restrictions and disability evaluation,4 +8633,Chiropractic IME with answers to questions from Insurance Company.,4 +7569,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6544,"Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.",11 +6944,Chronic snoring in children,36 +3943, A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,10 +3869," L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.",23 +11304,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +7007,The client was referred for evaluation of cataracts bilaterally,20 +11296,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +377, Patient with a three-day history of emesis and a four-day history of diarrhea,15 +6087,Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 +3499," Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.",15 +11116,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4650,CT Abdomen and Pelvis with contrast,21 +7504,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +12287,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3583," Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. ",14 +490, Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.,38 +3186, Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.,27 +6372,Well child - Left lacrimal duct stenosis,29 +6795,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +10163,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +10751,Mother states he has been wheezing and coughing.,0 +1908," Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.",38 +6336,Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The case is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.,11 +9490,A sample note on Rheumatoid Arthritis,34 +10200,A sample note on Rheumatoid Arthritis,34 +5484,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +3393," Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",27 +10213,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +9767,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5205,"Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +5659,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 +6750,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,29 +8309,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +69, Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.,38 +1764, Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.,24 +10123,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +2922, Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,35 +3983, Sample female physical exam.,15 +3693, Noncontrast CT abdomen and pelvis per renal stone protocol.,33 +1928, MRI cervical spine.,22 +3046, Left temporal craniotomy and removal of brain tumor.,23 +4660,"Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.",23 +11560,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10590,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +5183,"Cystoscopy, cystocele repair, BioArc midurethral sling.",39 +3966, Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar.,33 +10177,Mother states he has been wheezing and coughing.,0 +2550, Consult for laparoscopic gastric bypass.,2 +570, Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. ,22 +8915,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +5682,Patient being referred for evaluation of glaucoma.,26 +10769,Autopsy - Homicide - Blunt force cranial trauma,1 +3679," Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.",22 +12558,A 23-year-old white female presents with complaint of allergies.,0 +1132, Ultrasound OB - followup for fetal growth.,24 +1145," Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. ",24 +11461,Preoperative visit for weight management with laparoscopic gastric banding,2 +6772,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 +2951, Belly button piercing for insertion of belly button ring.,6 +1940, 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.,14 +2009," Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",23 +9357,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4695,"Cerebrovascular accident (CVA). The case presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.",12 +4801,"Creation of AV fistula, left wrist in the anatomic snuffbox.",21 +2199, Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +11498,Dietary consultation for carbohydrate counting for type I diabetes.,9 +8478,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +3474, Underwent tonsillectomy and adenoidectomy two weeks ago. ,11 +5473,"The patient with recurrent nongranulomatous anterior iritis and most recently, discomfort in left eye associated with headache and photophobia.",26 +8180,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +2906," The thoracic spine was examined in the AP, lateral and swimmer's projections.",33 +4907,"Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +3548," Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +2163, Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.,28 +9434,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9688,A sample note on Rheumatoid Arthritis,34 +2479," Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.",22 +3376, CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.,21 +3659, Nephrology office visit for followup of microscopic hematuria.,25 +3003, An example of a physical exam,15 +2947," Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.",35 +8312,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8775,Dietary consultation for gestational diabetes.,9 +8012,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +6188,Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 +6157,Preop evaluation regarding gastric bypass surgery.,2 +10145,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +6774,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 +2387, Dental prophylaxis under general anesthesia.,38 +3156, CT of abdomen with and without contrast. CT-guided needle placement biopsy.,38 +5778,Aftercare of multiple trauma from an motor vehicle accident.,10 +3747," Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",38 +12440,Autopsy - Homicide - Blunt force cranial trauma,1 +8349,A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,20 +11392,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +8889,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +7771,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +2757, Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.,39 +11667,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9820,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4795,"CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",22 +402, Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,27 +6595,Noncontrast CT abdomen and pelvis per renal stone protocol.,21 +1923, Invasive carcinoma of left breast. Left modified radical mastectomy.,24 +9644,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1516, Patient being referred for evaluation of glaucoma.,26 +6965,"Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +10013,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +10418,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3574, Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,38 +4575,The client with a recent change in bowel function and hematochezia.,14 +3920," Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. ",3 +10797,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +2516," Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",26 +9865,Dietary consultation for gestational diabetes.,9 +2505," Cervical cone biopsy, dilatation & curettage",38 +3633, Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.,22 +6483,Falls at home. Anxiety and depression. The client had been increasingly anxious and freely admitted that she was depressed at home.,32 +5054,"The case presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",24 +4344,"Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.",14 +2730," Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +10341,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +1559," Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.",15 +6166,Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 +11823,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9542,Cause of death - Anoxic Encephalopathy,1 +2736, Well child - Left lacrimal duct stenosis,5 +6085,Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.,16 +7252,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12231,Mother states he has been wheezing and coughing.,0 +9704,A sample note on Rheumatoid Arthritis,34 +6444,Patient today with ongoing issues with diabetic control.,13 +12382,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +10477,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6433,Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,11 +5715,Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 +3652," A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.",5 +445, Right hip osteoarthritis. Total hip replacement on the right side.,38 +1838," Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",21 +10405,Initial evaulation - neck and back pain.,4 +172," Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 +10802,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +1944, The patient is status post C3-C4 anterior cervical discectomy and fusion.,22 +7977,Mother states he has been wheezing and coughing.,0 +223, Most commonly used phrases in physical exam.,25 +11333,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +9039,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +341," Sample normal ear, nose, mouth, and throat exam.",5 +3504," Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",38 +8966,Mother states he has been wheezing and coughing.,0 +10660,Work restrictions and disability evaluation,18 +10107,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +3669, Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back pain referring into the left side. ,28 +6031,Urgent cardiac catheterization with coronary angiogram.,12 +1108," A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",22 +9158,Occupational medicine consult with questions-answers and records review.,18 +197," Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +11429,Occupational medicine consult with questions-answers and records review.,18 +7683,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +1666," Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.",3 +1978, Inguinal herniorrhaphy. A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ,38 +2023, A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,10 +8571,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2067," 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.",27 +6435,"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and therapy planning.",32 +8931,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +2044, Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,10 +9263,Dietary consultation for carbohydrate counting for type I diabetes.,9 +1173, Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,33 +3445," Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.",14 +8458,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +12335,A sample note on Rheumatoid Arthritis,34 +3757," Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.",22 +1226," Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.",15 +10019,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +8893,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +10052,The case is being referred for evaluation of diabetic retinopathy.,20 +6709,Qualified healthcare evaluation report of a patient with back pain.,18 +4243,"The client has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 +9644,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6518,Complete eye examination - Normal eye and vision exam.,26 +9341,Patient presents for care of suspected rheumatoid arthritis.,34 +10456,Elevated cholesterol and is on medication to lower it.,9 +9058,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +10471,Work restrictions and disability evaluation,4 +11516,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +1990, An example/template for a routine normal male physical exam.,15 +10695,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +10197,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +10948,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8234,Patient scheduled for laparoscopic gastric bypass.,2 +5503,Circumcision in an older person,39 +11540,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4476,Left temporal craniotomy and removal of brain tumor.,22 +9998,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +10241,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +9425,Is it BNP or BMP?,19 +3418," Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.",31 +941," Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee.",27 +12506,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +10496,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +3598," Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.",35 +3893, Patient dropped a weight on the dorsal aspects of his feet.,12 +2407, Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,26 +5853,"Toenails are discolored, thickened, and painful - Onychomycosis",31 +1318," Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",27 +12584,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2249," Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.",15 +5623,A simple note on Acne Vulgaris.,8 +10008,Incision and drainage (I&D) of buttock abscess.,8 +3635," Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.",38 +9130,Consult for laparoscopic gastric bypass.,2 +4134,"Patient with hypertension, dementia, and depression.",15 +12318,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5274,Pediatric Gastroenterology - Rectal Bleeding Consult.,29 +9492,A sample note on Rheumatoid Arthritis,34 +2637," Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.",38 +2575, Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.,38 +6859,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear ache resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",29 +1146," Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.",38 +3662, Excisional breast biopsy with needle localization. The skin overlying the needle tip was incised in a curvilinear fashion. ,38 +11080,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +108," Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",38 +10582,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7080,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8476,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1381," Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",38 +5238,Patient with immune thrombocytopenia,35 +7650,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1324," Patient with several medical problems - numbness, tingling, and a pain in the toes.",5 +3916," Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.",10 +9092,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +9362,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +4947,Follow up update on case with left carotid angioplasty and stent placement.,20 +7570,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8858,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +5706,Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,16 +7251,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +1223," Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",38 +9334,Elevated cholesterol and is on medication to lower it.,9 +11370,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +11242,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +7424,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4833,Consult and Spinal fluid evaluation in a 15-day-old,29 +5624,"Left orchiopexy. Ectopic left testis. The client did have an MRI, which confirmed ectopic testis located near the pubic tubercle.",39 +7430,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +8289,Dietary consultation for carbohydrate counting for type I diabetes.,9 +10748,Mother states he has been wheezing and coughing.,0 +9242,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8235,Patient scheduled for laparoscopic gastric bypass.,2 +3958," Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.",27 +3704," 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.",15 +9424,Is it BNP or BMP?,19 +3442, The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,15 +11112,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11734,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +3925, Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,38 +3758," Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.",11 +6630,"Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +1172, This patient was seen in clinic for a school physical.,29 +10147,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +10667,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +8955,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +4408,"Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.",33 +6965,"Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",21 +452," Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).",5 +11524,Qualified medical evaluation report of a client with back pain.,4 +2546," Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.",38 +10464,"Records review. The patient developed shooting ache about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +1936, Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,28 +702," Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ",15 +2047, Right subclavian triple lumen central line placement,38 +4936,Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,29 +2014, Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +12322,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +1994, Fall/loss of consciousness.,5 +4734,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +1583, Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.,38 +6778,Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +1774, Questionable need for antibiotic therapy for possible lower extremity cellulitis.,5 +10403,Initial evaulation - neck and back pain.,4 +3877, Insertion of central venous line and arterial line and transesophageal echocardiography probe.,38 +9027,MRI report Cervical Spine (Chiropractic Specific),4 +3580," Patient with hypertension, dementia, and depression.",5 +9710,A sample note on Rheumatoid Arthritis,34 +7645,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6153,Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.,28 +11941,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +8636,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10126,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +8497,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +7216,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9939,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +4204,Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 +5739,"The case comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.",32 +9943,Occupational medicine consult with questions-answers and records review.,18 +848," This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",12 +8007,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +5079,"Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and ache for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",39 +8699,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +1423," Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",38 +2267, A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. ,33 +7276,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7493,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +2509," A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",15 +11374,A sample note on Rheumatoid Arthritis,34 +8906,"Followup diabetes mellitus, type 1.",13 +6758,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +2687, Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. ,15 +3427," Request for consultation to evaluate stomatitis, possibly methotrexate related.",5 +3239," Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.",38 +4415,A 2-month-old female with 1-week history of congestion and fever x2 days.,29 +7338,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3154, Trauma/ATV accident resulting in left open humerus fracture.,27 +12055,Preop evaluation regarding gastric bypass surgery.,2 +6494,Preoperative visit for weight management with laparoscopic gastric banding,2 +7425,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +8599,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +11344,"Specimen labeled ""sesamoid bone left foot"".",19 +284," Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ",38 +8202,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +5171,"Chronic kidney disease, stage IV, secondary to polycystic kidney disease. Hypertension, which is finally better controlled. Metabolic bone disease and anemia.",35 +11223,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +5920,Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,16 +10811,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5956,"Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +9083,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +2527, X-RAY of the soft tissues of the neck.,33 +11379,MRI report Cervical Spine (Chiropractic Specific),4 +9661,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9923,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +3683, Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,38 +1536, Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,7 +3012," Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left.",3 +7339,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4787,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +6455,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +2397," Repair of left inguinal hernia indirect. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",38 +8595,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +3508, Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion.,24 +1586, Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.,38 +2233, Superior labrum anterior and posterior lesion repair.,38 +2539, Followup on weight loss on phentermine.,35 +1498," Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.",38 +6090,Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +82, Inguinal orchiopexy procedure.,38 +1683, Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed,39 +8726,Work restrictions and disability evaluation,18 +5352,Patient in ER due to colostomy failure - bowel obstruction.,12 +7432,"Specimen labeled ""sesamoid bone left foot"".",19 +11401,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +6747,CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,23 +12048,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +10889,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8408,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6987,"Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",31 +8869,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5571,"Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 +6020,Costochondral Cartilage Injection,28 +3672, Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,38 +2475, The patient underwent a total vaginal hysterectomy.,24 +9453,"Specimen labeled ""sesamoid bone left foot"".",19 +10092,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +5345,Occupational medicine consult with questions-answers and records review.,18 +11577,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10455,Elevated cholesterol and is on medication to lower it.,9 +4254,Urine leaked around the ostomy site for his right sided nephrostomy tube. The client had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,21 +5247,Dietary consultation for gestational diabetes.,9 +5960,Lower lid blepharoplasty.,26 +5668,"Specimen labeled ""sesamoid bone left foot"".",19 +10924,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +446," Right and left heart catheterization, coronary angiography, left ventriculography.",3 +3792, Bender-Gestalt Neurological Battery and Beck testing.,32 +4764,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",35 +7594,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9447,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +12329,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +953, A 17-year-old male with oligoarticular arthritis of his right knee.,5 +10077,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +9903,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5086,"Left neck dissection. Metastatic papillary cancer, left neck. The client had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.",16 +6777,Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +10310,Patient today with ongoing issues with diabetic control.,13 +8442,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +11111,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6682,"Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",31 +2200," Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.",21 +6300,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +11012,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2684, Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,27 +5489,Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,26 +8973,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +9484,A sample note on Rheumatoid Arthritis,34 +3694," History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",22 +1215, Chest CT - Thymoma and history of ocular myasthenia gravis.,33 +10322,Consultation for wrist pain.,4 +11888,Work restrictions and disability evaluation,4 +5145,Evaluation for bariatric surgery.,2 +1006," Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.",28 +8089,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +5025,"Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 +4465,Patient in ER with upper respiratory infection,12 +6778,Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +4706,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +11134,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11898,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +7595,Mother states he has been wheezing and coughing.,0 +2852," 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.",3 +12056,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +2999, Common description of colonoscopy,38 +12625,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9012,A sample note on Rheumatoid Arthritis,34 +2172, A 53-year-old female with left knee pain being evaluated for ACL tear.,27 +9201,Consultation for wrist pain.,4 +1521, Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. ,27 +6835,The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.,26 +3565," Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.",39 +1221," A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.",14 +8674,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +676," Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +8743,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +29, Foul-smelling urine and stomach pain after meals.,14 +1101," Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.",38 +5664,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",10 +3762, Bilateral inguinal hernia. Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,39 +11837,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +520, Common CT Head template.,33 +4223,"Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.",39 +8975,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +1721, Bilateral sacroiliac joint injections,28 +2903," Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.",38 +6580,"Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 +11014,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +10063,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +5182,"Cystoscopy, cystocele repair, BioArc midurethral sling.",39 +8010,A sample note on Rheumatoid Arthritis,34 +1729, Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 +9037,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +3065," 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.",38 +5875,"A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",29 +4398,Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,35 +5656,"Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.",26 +1943," Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",38 +4401,The client is admitted with a diagnosis of acute on chronic renal insufficiency.,21 +8174,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +713," Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.",38 +3970, Left laparoscopic hand-assisted nephrectomy.,21 +4455,"Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past clinical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.",22 +2175," Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.",38 +7805,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +4574,The client with a recent change in bowel function and hematochezia.,14 +10730,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +7451,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +8141,Encephalopathy related to normal-pressure hydrocephalus.,30 +10262,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +71," Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. ",10 +4067,HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 +7392,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +10655,A 23-year-old white female presents with complaint of allergies.,0 +921, Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,38 +11163,A sample note on Rheumatoid Arthritis,34 +561, CT scan of the abdomen and pelvis without and with intravenous contrast.,33 +11, Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias,38 +6506,"Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",11 +4807,MRI C-spine: C4-5 Transverse Myelitis.,22 +2359, A 32-year-old male with shoulder pain.,33 +11803,Autopsy - Asphyxia due to ligature strangulation.,1 +5258,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.,23 +1135," Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.",38 +3717, Echocardiogram was performed including 2-D and M-mode imaging.,3 +2797, Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,23 +8254,"Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36. Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.",7 +5753,Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.,28 +1925," Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",26 +8131,Punch biopsy of right upper chest skin lesion.,8 +5989,Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 +4672,"Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 +6773,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 +11607,A 23-year-old white female presents with complaint of allergies.,0 +4557,"Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",22 +8850,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +5041,Psychosocial Evaluation of client before kidney transplant.,32 +5765,Evaluation for right L4 selective nerve root block.,28 +6303,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +4474,"Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.",24 +4259,"The client is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",24 +9652,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1602," Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.",27 +1437, Echocardiogram was performed including 2-D and M-mode imaging.,33 +10076,Dietary consultation for gestational diabetes.,9 +839, 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. ,24 +9925,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +8645,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +5625,"Left orchiopexy. Ectopic left testis. The case did have an MRI, which confirmed ectopic testis located near the pubic tubercle.",39 +5943,"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +11753,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8036,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +9029,MRI report Cervical Spine (Chiropractic Specific),4 +1622, Psychiatric consultation for substance abuse.,5 +6389,"Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",26 +6922,Complete heart block with pacemaker malfunction and a history of Shone complex.,12 +9044,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +6639,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +4533,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",35 +3059, A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.,3 +5814,Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 +4887,Transforaminal epidural steroid block with fluoroscopy.,28 +3339, CT Abdomen & Pelvis W&WO Contrast,33 +1387," Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.",3 +10879,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +11597,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +96, Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. ,38 +10776,A sample note on Rheumatoid Arthritis,34 +7663,A sample note on Rheumatoid Arthritis,34 +9913,Work restrictions and disability evaluation,4 +7330,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5937,Patient presents with complaint of lump in the upper outer quadrant of the right breast,16 +1034, History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.,5 +2711, Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,38 +5821,Discharge summary of a case with depression and high risk behavior.,32 +7765,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +8724,Work restrictions and disability evaluation,18 +4703,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +206, Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,3 +8155,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +327, The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.,5 +11826,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9931,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +6939,"Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.",28 +3740, ,5 +4590,"Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.",28 +8761,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +5996,Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,16 +3543," The patient is 14 months old, comes in with a chief complaint of difficulty breathing. ",12 +2893, Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.,3 +10419,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +563, Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 +4697,"Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.",24 +4918,Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,24 +10030,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +2248," The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 +11716,A sample note on Rheumatoid Arthritis,34 +5383,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +2529," Closure of bladder laceration, during cesarean section.",39 +8679,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +10578,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12066,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +4701,A 34-year old female with no fetal heart motion noted on office scan.,24 +5421,"A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 +5928,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,12 +1427, Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 +1190," Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.",10 +5113,"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 +7641,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6722,Left temporal craniotomy and removal of brain tumor.,23 +3313, Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,38 +5486,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +12011,"Specimen labeled ""sesamoid bone left foot"".",19 +5010,"This is a 14-month-old baby boy Caucasian who came in with presumptive identification of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",29 +10727,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +11675,"Specimen labeled ""sesamoid bone left foot"".",19 +625," Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",10 +4390,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4483,Esophagogastroduodenoscopy and colonoscopy with polypectomy,14 +7529,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9212,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8223,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3693, Noncontrast CT abdomen and pelvis per renal stone protocol.,33 +6776,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 +10717,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9042,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +736, Vitrectomy under local anesthesia.,26 +3514, The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.,22 +9839,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10708,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10283,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +5072,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +585, Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.,14 +2819, An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 +9614,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4969,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +8313,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8607,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +2121, Normal child physical exam template.,15 +10826,Autopsy of a white female who died of acute combined drug intoxication.,1 +3023," CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",27 +10892,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1018," Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",12 +9486,A sample note on Rheumatoid Arthritis,34 +3241," Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.",38 +7649,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7197,Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,32 +1032," Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",23 +9327,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6068,Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,10 +905," Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ",14 +7996,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +6886,"Normal physical exam template. Well developed, well nourished, in no acute distress.",25 +10475,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10816,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +2806, Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.,23 +3798," Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3.",38 +9787,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11801,Autopsy - Asphyxia due to ligature strangulation.,1 +10344,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 +9324,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6190,Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia.,11 +10668,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +164," Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.",38 +1623, Common description of colonoscopy,14 +11553,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +11901,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +6569,Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 +11023,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11896,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +302," History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.",33 +778," Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.",3 +11495,Initial evaulation - neck and back pain.,4 +2395," Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",38 +8846,Dietary consultation for diabetes during pregnancy.,9 +5658,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 +8977,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +8006,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +1995, Common description of colonoscopy,38 +3353, EGD with dilation for dysphagia.,14 +3731, Left retrosigmoid craniotomy and excision of acoustic neuroma.,38 +7180,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +11184,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +11526,Elevated cholesterol and is on medication to lower it.,9 +4050,"Incision and drainage and removal of foreign body, right foot. The client has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +9796,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2750, CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.,3 +4325,"Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 +4966,"Patient had some cold symptoms, was treated as bronchitis with antibiotics.",10 +7390,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +10291,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +8994,Autopsy - Homicide - Blunt force cranial trauma,1 +2077," Medical management, status post left total knee arthroplasty.",5 +4951,Knee injection,28 +5480,"Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",12 +4343,"Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies. Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.",14 +9504,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +4239,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",15 +582," Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.",38 +6781,Blepharoplasty with direct brow repair.,26 +8756,Occupational medicine consult with questions-answers.,18 +6476,Normal child physical exam template.,29 +2159, 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.,14 +5750,"Phacoemulsification of cataract, extraocular lens implant in left eye.",26 +4044,CT Brain: Midbrain hemangioma,33 +8283,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +6828,13 years old complaining about severe ear discomfort - Chronic otitis media.,11 +8295,Diagnosis of benign rolandic epilepsy.,20 +11171,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +4432,Newly diagnosed head and neck cancer. The client was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 +2779," Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",5 +3223," Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",11 +6073,The patient's main complaint is vertigo. The case is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +10695,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +3260," Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",26 +6508,"Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.",23 +10265,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +11973,Occupational medicine consult with questions-answers.,18 +127," The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",5 +11911,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +4175,"Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.",14 +4982,A two week well-child check.,29 +3490," Pneumatosis coli in the cecum. Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.",5 +11353,Consultation for left foot pain.,4 +9710,A sample note on Rheumatoid Arthritis,34 +4423,Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 +4517,A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,24 +4146,"Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.",11 +8504,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6403,"Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The case is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.",23 +3375," Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",31 +11882,Patient presents for care of suspected rheumatoid arthritis.,34 +480," C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",38 +1448," Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.",38 +8917,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +10380,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +1220," Right shockwave lithotripsy, cystoscopy, and stent removal x2.",38 +7923,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +4569,"Patient with several clinical problems - mouth being sore, cough, right shoulder pain, and neck pain",35 +2674," Transurethral resection of the bladder tumor (TURBT), large.",39 +1267, Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,35 +10183,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +12658,Patient presents for therapy of suspected rheumatoid arthritis.,34 +6534,"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.",21 +11056,A sample note on Rheumatoid Arthritis,34 +11654,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9309,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +2363, CT brain (post craniectomy) - RMCA stroke and SBE.,33 +282," Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",24 +12483,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +10579,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3432," The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. ",5 +1187," Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",15 +11453,Consultation for wrist pain.,4 +8865,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10431,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7238,Mother states he has been wheezing and coughing.,0 +1558, 2-month-old female - increased work of breathing.,12 +3991, Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,22 +4651,She was admitted following an overdose of citalopram and warfarin. The case has had increasing depression and has been under stress as a result of dissolution of her second marriage.,32 +12257,A sample note on Rheumatoid Arthritis,34 +7946,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +3945, Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,28 +8697,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +8680,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +6423,"Psychiatric consultation has been requested as the client has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",32 +4319,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 +6314,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +11058,A sample note on Rheumatoid Arthritis,34 +3936," Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.",3 +9113,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8085,Consult for laparoscopic gastric bypass.,2 +11501,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +6228,"Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.",28 +9355,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7395,Chiropractic IME with answers to questions from Insurance Company.,4 +5990,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,28 +7465,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +9927,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +414, Patient with immune thrombocytopenia,16 +7689,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +9129,Consult for laparoscopic gastric bypass.,2 +2526, The patient has a possibly torsion detorsion versus other acute testicular problem. ,39 +8238,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 +11131,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2421," Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. ",27 +2512," The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",38 +12163,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4597,"Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.",22 +49, MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 +1094, Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. ,11 +2909," Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.",5 +12068,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +7203,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5045,Psychiatric Assessment of a case with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 +5019,Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.,35 +5229,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +6992,"Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.",21 +12310,Patient presents for care of suspected rheumatoid arthritis.,34 +4104,"Right shoulder impingement syndrome, right suprascapular neuropathy.",22 +8947,Consultation for left foot pain.,4 +6532,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +8126,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +8220,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +1716, Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,33 +11120,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9507,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +12143,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8988,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2104," Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.",5 +9016,A sample note on Rheumatoid Arthritis,34 +191, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,3 +1021, Tonsillectomy and adenoidectomy. Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,38 +7332,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4840,"Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.",22 +218," Open reduction, nasal fracture with nasal septoplasty.",11 +5129,"Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.",10 +8703,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +3416, Echocardiogram and Doppler,3 +12250,Autopsy - Homicide - Blunt force cranial trauma,1 +7786,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +3436," Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",38 +6109,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +60, Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,38 +12662,A sample note on Rheumatoid Arthritis,34 +3939," Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. ",24 +5555,Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 +12139,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3675, Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 +1872, A sample note on Rheumatoid Arthritis,34 +12246,Autopsy - Homicide - Blunt force cranial trauma,1 +11950,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +10701,Dietary consultation for diabetes during pregnancy.,9 +4437,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",35 +1262, Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11678,"Specimen labeled ""sesamoid bone left foot"".",19 +8658,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +10615,Chiropractic IME with answers to questions from Insurance Company.,4 +12466,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +6299,Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 +12639,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1526, The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,3 +11291,Dietary consultation for gestational diabetes.,9 +4773,The client states that he feels sick and weak.,35 +8662,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +7751,Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,25 +6825,"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 +181," Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. ",27 +2296," One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.",35 +7844,The case is being referred for evaluation of diabetic retinopathy.,20 +11536,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +1474," Re-excision of squamous cell carcinoma site, right hand.",16 +5983,Patient has prostate cancer with metastatic disease to his bladder. The client has had problems with hematuria in the past. The client was encouraged to drink extra water and was given discharge instructions on hematuria.,12 +9163,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +11235,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +8809,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +6814,The client is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness.,11 +6289,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,16 +7689,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +729, Template for History and Physical for a newborn.,5 +6836,The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.,26 +5683,Patient being referred for evaluation of glaucoma.,26 +8247,"9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.",20 +1213, Sepsis due to urinary tract infection.,15 +781, Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +6945,Chronic snoring in children,36 +10066,Occupational medicine consult with questions-answers.,18 +518," Right knee total arthroplasty. Degenerative osteoarthritis, right knee.",38 +600, A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 +6371,Migraine headache - The case was seen in the urgent care.,12 +2181, Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,38 +6265,Patient presents to the emergency department (ED) with rectal bleeding and discomfort on defecation.,12 +7801,Incision and drainage (I&D) of buttock abscess.,8 +1109," Cystoscopy, cryosurgical ablation of the prostate.",39 +10459,"The case with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +12193,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7437,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +6556,Cause of death - Anoxic Encephalopathy,1 +8325,Bilateral reduction mammoplasty for bilateral macromastia,6 +8844,Dietary consultation for diabetes during pregnancy.,9 +10347,Cause of death - Anoxic Encephalopathy,1 +8278,Initial evaulation - neck and back pain.,4 +4162,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +2157, Patient returns for his first followup after shunt surgery.,5 +2251," Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.",24 +4862,"Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",10 +2342," Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",3 +10522,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +920," Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.",3 +7120,Caudal epidural steroid injection without fluoroscopy.,28 +12465,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +11719,A sample note on Rheumatoid Arthritis,34 +11071,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +7343,Patient presents for care of suspected rheumatoid arthritis.,34 +5317,"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.",25 +8250,"Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,",8 +572," 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",5 +11972,Occupational medicine consult with questions-answers.,18 +1540," Left orchiectomy, scrotal exploration, right orchidopexy.",39 +42," Excision of basal cell carcinoma. Closure complex, open wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured silicone gel implants",16 +7258,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +11182,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3084," Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.",27 +3597, Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +6092,Standard celiac plexus block procedure note.,28 +1372," Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +4543,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",35 +7533,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5139,"Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.",39 +1419, Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,15 +11102,Patient presents for care of suspected rheumatoid arthritis.,34 +1169, LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,38 +4092,"The client is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The client presents for her fetal anatomical survey.",24 +6026,"Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 +1462, Bilateral open carpal tunnel release.,27 +1663, Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.,38 +7651,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +234," Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",38 +12512,Elevated cholesterol and is on medication to lower it.,9 +5544,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +4632,Patient with immune thrombocytopenia,16 +9831,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6089,Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +121," Macular edema, right eye. Insertion of radioactive plaque, right eye with lateral canthotomy. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy. ",38 +7410,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6524,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,8 +7095,Bilateral reduction mammoplasty for bilateral macromastia,6 +6017,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant.,26 +8203,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +10780,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +10775,A sample note on Rheumatoid Arthritis,34 +175, Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,11 +8166,Preoperative visit for weight management with laparoscopic gastric banding,2 +10952,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2512," The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.",38 +11521,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7877,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +6206,Right pleural effusion and suspected malignant mesothelioma.,16 +9351,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7655,Patient presents for care of suspected rheumatoid arthritis.,34 +3726," Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.",16 +155, Pain management for post-laminectomy low back syndrome and radiculopathy. ,5 +9875,Dietary consultation for diabetes during pregnancy.,9 +976, A 19-year-old right-handed male injured in a motor vehicle accident.,27 +7673,"Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +7797,Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.,25 +12417,Dietary consultation for diabetes during pregnancy.,9 +1681, The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. ,32 +1218," Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",14 +11723,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +4880,"Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",10 +5974,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid care to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +2528, Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +2635, Tonsillectomy. Tonsillitis. McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. ,38 +7098,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +4720,Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 +10440,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +8542,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7787,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +7710,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +6879,Bilateral lumbar sympathetic block. The client was in the prone position and the back prepped with Betadine. The client was given sedation and monitored.,28 +9905,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6713,Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,23 +1730, Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis,14 +9689,A sample note on Rheumatoid Arthritis,34 +3767, A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,5 +6350,"Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. The case was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.",26 +6291,"Adenotonsillectomy, primary, case under age 12.",11 +7564,A 23-year-old white female presents with complaint of allergies.,0 +12522,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +12238,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8457,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +3753, Bilateral reduction mammoplasty for bilateral macromastia,6 +6482,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +2586, Full mouth dental rehabilitation in the operative room under general anesthesia.,38 +505," Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.",35 +12325,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3317, 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.,22 +11944,Chiropractic IME with answers to questions from Insurance Company.,4 +7354,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +2717, Incision and drainage of right buccal space abscess and teeth extraction.,38 +4768,Polycythemia rubra vera. The client is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 +4184,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 +10215,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +6899,Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.,28 +3962, Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.,38 +12187,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6128,A 66-year-old client who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 +4009,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,15 +10573,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +1294, Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,38 +4130,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +809," Colonoscopy - Diarrhea, suspected irritable bowel",14 +10480,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +114," Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.",38 +11478,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6305,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +4183,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 +8473,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1371, A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,10 +5828,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +8738,Evaluation for bariatric surgery.,2 +2268," Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.",3 +4753,"Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.",28 +1147," Patient admitted with abdominal pain, nausea and vomiting.",15 +6005,Open septorhinoplasty with placement of bilateral spreader grafts. Bilateral lateral osteotomies.,11 +12613,A sample note on Rheumatoid Arthritis,34 +5272,"Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.",23 +9924,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +8588,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +11585,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +2582," Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography.",38 +4352,Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,23 +8340,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +204, Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,38 +8382,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +11305,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +7681,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7935,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +7746,An example/template for a routine normal male physical exam.,25 +575, Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,5 +2385, Axial images through the cervical spine with coronal and sagittal reconstructions.,22 +6416,Consult for laparoscopic gastric bypass.,2 +2679," Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",21 +4373,"Patient has trouble with walking and balance, with bladder control, and with thinking and memory.",22 +7275,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1204, Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.,33 +5772,"Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +952," The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. ",15 +11227,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +10903,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +2064, Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 +1393, Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. ,10 +11231,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +347," She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.",14 +7935,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +6198,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +1573, Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.,3 +2306, Psychosocial evaluation of kidney donor. Questions - Answers,32 +5968,Laparoscopic right partial nephrectomy due to right renal mass.,21 +9631,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2150, The patient needing to be reintubated due to a leaking ET tube. The patient is recently postoperative. ,38 +9626,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5837,Patient complains of constipation. Has not had BM for two days.,25 +413," Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",29 +1356, A 12-year-old young man with sinus congestion.,15 +3316," Patient with suspected nasal obstruction, possible sleep apnea. ",5 +4923,"Follow up consultation, second opinion, foreskin.",39 +7887,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 +6064,"C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",23 +1497, 1-year well child check.,29 +11250,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +9650,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4928,"Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.",31 +642," Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.",10 +4206,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,15 +8902,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +10772,A sample note on Rheumatoid Arthritis,34 +11234,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +7498,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3459, Elevated PSA with nocturia and occasional daytime frequency.,39 +838, Cardiology office visit sample note.,25 +4007,MRI Brain: Thrombus in torcula of venous sinuses.,33 +676," Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +9014,A sample note on Rheumatoid Arthritis,34 +5030,"This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy.",35 +1730, Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis,14 +806, Consultation for FCR tendinitis,27 +7715,"Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +2110, A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,3 +9776,Patient presents for care of suspected rheumatoid arthritis.,34 +12641,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12041,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +11852,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +5911,The client underwent an overnight polysomnogram.,36 +10966,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8629,Chiropractic IME with answers to questions from Insurance Company.,4 +5675,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 +6594,Noncontrast CT abdomen and pelvis per renal stone protocol.,21 +5861,Left hip fracture. The case is a 53-year-old female with probable pathological fracture of the left proximal femur.,12 +4817,Chiropractic IME with answers to questions from Insurance Company.,4 +4975,"A white female who presents for complete physical, Pap and breast exam.",24 +1709, Reflex sympathetic dystrophy of both lower extremities.,22 +11860,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1287, Circumcision in an older person,39 +2459," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +9078,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +2066, Echocardiogram with color flow and conventional Doppler interrogation.,33 +7412,Dietary consultation for gestational diabetes.,9 +1120, Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,27 +6571,Psychiatric consultation of client with lethargy.,32 +1001, H&P for a female with Angina pectoris.,5 +8240,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +6671,Psychiatric consultation for alcohol withdrawal and dependance.,32 +4203,Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 +9600,Patient presents for care of suspected rheumatoid arthritis.,34 +543, The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. ,35 +2237, Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,38 +2241," Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",39 +10588,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +3492," The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.",33 +898, A 51-year-old male with chest pain and history of coronary artery disease.,3 +5135,The client is being referred for evaluation of diabetic retinopathy.,20 +8114,Completion thyroidectomy with limited right paratracheal node dissection.,13 +10417,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +6811,"Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,",8 +511, A sample note on Cataract,26 +8381,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +5105,Patient is here to discuss possible open lung biopsy.,35 +6722,Left temporal craniotomy and removal of brain tumor.,23 +7078,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +7436,Mother states he has been wheezing and coughing.,0 +2080, Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,5 +10314,Encephalopathy related to normal-pressure hydrocephalus.,30 +7830,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +9451,"Specimen labeled ""sesamoid bone left foot"".",19 +8426,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +4525,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +12188,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11201,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +6766,The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and care planning.,32 +8472,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +8815,Occupational medicine consult with questions-answers and records review.,18 +6311,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear ache resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",12 +11561,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10676,Dietary consultation for gestational diabetes.,9 +892," School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 +1078, MRI of lumbar spine without contrast to evaluate chronic back pain.,33 +1904," Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",39 +7664,A sample note on Rheumatoid Arthritis,34 +7727,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +1547, Ultrasound BPP - Advanced maternal age and hypertension.,24 +1396, Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. ,3 +11369,Autopsy - Homicide - Blunt force cranial trauma,1 +9934,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +1099, Patient in ER due to colostomy failure - bowel obstruction.,12 +7775,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +9984,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +3838, Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,11 +1814, A 53-year-old female with left knee pain being evaluated for ACL tear.,33 +1357, The patient has NG tube in place for decompression.,35 +3721, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,38 +5360,Nephrology office visit for followup of CKD.,25 +4466,Chiropractic IME with answers to questions from Insurance Company.,20 +1564, Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. ,15 +8877,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating discomfort in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +12646,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11905,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9882,Mother states he has been wheezing and coughing.,0 +2428, Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,15 +11530,Patient presents for care of suspected rheumatoid arthritis.,34 +958," Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +9772,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5026,"Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",10 +9955,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +6094,Standard celiac plexus block procedure note.,28 +9379,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +860, Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax.,16 +106," Negative for any nausea, vomiting, fevers, chills, or weight loss.",15 +10454,Elevated cholesterol and is on medication to lower it.,9 +4368,"Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.",14 +6452,Encephalopathy related to normal-pressure hydrocephalus.,30 +8614,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +7868,Dietary consultation for gestational diabetes.,9 +3252, Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,38 +2234," Negative for any nausea, vomiting, fevers, chills, or weight loss.",5 +7245,Autopsy - Homicide - Blunt force cranial trauma,1 +2644," Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.",38 +1761, The patient has NG tube in place for decompression.,15 +831," Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",16 +8827,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +7025,Sample/template for a normal male multisystem exam.,25 +6408,13 years old complaining about severe ear ache - Chronic otitis media.,29 +8222,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +487," A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.",38 +10834,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +3827, Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,33 +3737, Common CT C-Spine template,33 +7047,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent identification of urinary tract infection on outpatient treatment with nitrofurantoin.,12 +3470, Patient with a three-day history of emesis and a four-day history of diarrhea,35 +9001,Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.,13 +11101,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8948,Consultation for left foot pain.,4 +3862," Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.",15 +9030,MRI report Cervical Spine (Chiropractic Specific),4 +2447, MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,33 +1832," Left below-the-knee amputation. Dressing change, right foot.",38 +473, The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.,38 +1072, Chest tube talc pleurodesis of the right chest.,38 +12350,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2373, History and Physical for right ankle sprain,5 +8097,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +8816,Occupational medicine consult with questions-answers and records review.,18 +1452, Patient today with multiple issues. ,35 +2454," History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).",15 +10944,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1359, CT scan of the abdomen and pelvis without and with intravenous contrast.,14 +139," Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",38 +8231,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +10598,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +4529,Sample for Neuropsychological Evaluation,32 +8527,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +3131," Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.",38 +10999,A 23-year-old white female presents with complaint of allergies.,0 +6437,"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and therapy planning.",32 +620, Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. ,24 +6035,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +3772," Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",10 +3054," Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.",14 +2719, Discharge summary of a patient with a BRCA-2 mutation.,10 +1781, Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,33 +9977,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +10942,Autopsy - Asphyxia due to ligature strangulation.,1 +7417,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +1544," Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 +12521,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8922,"Specimen labeled ""sesamoid bone left foot"".",19 +5069,"Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",35 +1350, A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,3 +7395,Chiropractic IME with answers to questions from Insurance Company.,4 +11966,Evaluation for bariatric surgery.,2 +8655,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +1664, Right middle ear exploration with a Goldenberg TORP reconstruction.,38 +2434, Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,38 +9509,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7850,Evaluation for bariatric surgery.,2 +1966," A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",38 +8387,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +5882,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +3786, Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.,14 +9021,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +6426,"The case is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.",29 +10207,A 21-channel digital electroencephalogram was performed on a case in the awake state.,36 +8072,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +4056,"Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 +11190,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +1545," Sample normal ear, nose, mouth, and throat exam.",15 +6853,"Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.",11 +5152,"Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",12 +9241,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4195,Procedure note on Keller Bunionectomy,31 +6557,Cause of death - Anoxic Encephalopathy,1 +6286,Occupational medicine consult with questions-answers and records review.,18 +3358, MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,27 +2230, 4-day-old with hyperbilirubinemia and heart murmur.,29 +7937,"Followup diabetes mellitus, type 1.",13 +11248,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2429," Primary low transverse cesarean section via Pfannenstiel incision. Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.",38 +2781, Upper gastrointestinal endoscopy.,14 +2192, Carotid Ultrasonic & Color Flow Imaging,3 +8841,Dietary consultation for diabetes during pregnancy.,9 +3074," The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.",10 +8215,Belly button piercing for insertion of belly button ring.,6 +11775,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2954, The patient was referred due to a recent admission for pseudoseizures.,5 +6743,Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 +8964,Mother states he has been wheezing and coughing.,0 +12406,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5815,Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,10 +11114,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2714, This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,12 +5282,"Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.",21 +3334, Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.,38 +6246,Patient presents with a chief complaint of chest ache admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 +9956,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +3083," Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.",3 +10004,Chiropractic IME with answers to questions from Insurance Company.,4 +5799,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 +5313,Penile injury and continuous bleeding from a penile laceration.,12 +5357,"Cystoscopy, cryosurgical ablation of the prostate.",39 +5725,Adenoidectomy procedure,11 +3767, A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,5 +11169,Work restrictions and disability evaluation,4 +4493,Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 +9217,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4973,Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 +1662, Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,22 +4210,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +6383,"Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",21 +2634, Chronic cholecystitis without cholelithiasis.,14 +8980,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +2069," Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. ",27 +7446,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +2747, Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 +2093, Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,22 +4683,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,22 +1473," Left inguinal herniorrhaphy, modified Bassini. Left inguinal hernia, direct.",38 +6985,"Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.",31 +10114,"Patient suffers from neck and lower back ache radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 +5582,Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.,10 +9333,Elevated cholesterol and is on medication to lower it.,9 +950, Colonoscopy in a patient with prior history of anemia and abdominal bloating.,14 +1455," Excision of lipoma, left knee. A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.",38 +439," A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",29 +12342,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4403,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +7537,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3599," Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.",38 +4560,Falls at home. Anxiety and depression. The case had been increasingly anxious and freely admitted that she was depressed at home.,22 +8295,Diagnosis of benign rolandic epilepsy.,20 +903, Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.,5 +1155," Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",27 +5639,"Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",16 +3110, Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,14 +7174,"Intercostal block from fourth to tenth intercostal spaces, left. Chest discomfort secondary to fractured ribs, unmanageable with narcotics.",28 +9323,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10609,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +6916,Incision and drainage of right buccal space abscess and teeth extraction.,7 +2074, Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,5 +3710," Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.",38 +8842,Dietary consultation for diabetes during pregnancy.,9 +10009,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2414, The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. ,38 +6008,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",12 +519," A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.",32 +8835,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +3261, Laparoscopic appendectomy. Acute appendicitis.,14 +9094,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +8918,"Specimen labeled ""sesamoid bone left foot"".",19 +7515,Patient presents for therapy of suspected rheumatoid arthritis.,34 +5520,"Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +9148,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +3259," Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates. Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.",11 +8706,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +966, Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 +11953,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +4245,Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal.,14 +1960, Sellar HCT - Pituitary mass,33 +257, Patient in ER due to colostomy failure - bowel obstruction.,14 +12599,Autopsy - Homicide - Blunt force cranial trauma,1 +6099,"This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.",32 +3690," Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.",24 +6197,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +7561,A 23-year-old white female presents with complaint of allergies.,0 +9084,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +7546,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6059,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +1053, Dietary consultation for gestational diabetes.,5 +1009, Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.,29 +9935,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8750,Occupational medicine consult with questions-answers.,18 +11316,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no discomfort that radiates from her back into her legs. She has had no associated weakness.",30 +9709,A sample note on Rheumatoid Arthritis,34 +2071, Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 +5336,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,12 +11810,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7953,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +94, Multiple stent placements with Impella circulatory assist device.,38 +2035," C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",23 +7092,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +5873,"A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.",29 +3456," A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.",31 +6546,Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 +753, Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 +6117,She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 +6288,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,16 +5992,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,28 +9258,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +3222, Lower Extremity Arterial Doppler,33 +7736,Chiropractic IME with answers to questions from Insurance Company.,20 +8334,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,6 +1101," Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.",38 +3109, Short-term memory loss (probable situational) and anxiety stress issues.,15 +11705,Autopsy - Homicide - Blunt force cranial trauma,1 +4195,Procedure note on Keller Bunionectomy,31 +4679,"Still having diarrhea, decreased appetite.",35 +6857,"Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",11 +5540,Psychiatric consultation for substance abuse.,32 +3095, Sentinel lymph node biopsy. Ultrasound-guided lumpectomy with intraoperative ultrasound.,38 +5422,"A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers.",16 +7528,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6287,Occupational medicine consult with questions-answers and records review.,18 +2894," Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. ",5 +11726,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +9969,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3579, Blepharoplasty procedure,26 +8187,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +12518,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +8347,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 +4968,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +5840,"Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",23 +3809, This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,24 +6134,A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The case was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,12 +10240,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +8760,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +2191," Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.",38 +4337,"Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +4624,"Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear.",11 +5446,Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 +6672,Sample/template for a normal female multisystem exam,25 +12416,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +4854,"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 +3361, ,5 +128, Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.,38 +8143,Encephalopathy related to normal-pressure hydrocephalus.,30 +3959," Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.",38 +9491,A sample note on Rheumatoid Arthritis,34 +11846,A sample note on Rheumatoid Arthritis,34 +2905," Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.",27 +1883, MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,27 +4929,"Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.",11 +7878,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +2312, Common description of EGD.,14 +10645,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +492, Ultrasound Abdomen - elevated liver function tests.,33 +7651,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5600,Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The client is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.,29 +7096,Bilateral reduction mammoplasty for bilateral macromastia,6 +2681," A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" ",22 +10246,Preop evaluation regarding gastric bypass surgery.,2 +5713,"The patient is admitted on a 72-hour involuntary care for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.",32 +1346, Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.,38 +212," Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. ",27 +166, Occupational medicine consult with questions-answers and records review.,18 +11156,A sample note on Rheumatoid Arthritis,34 +4303,"This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.",12 +3151," Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. ",30 +6861,"Onychomycosis present, #1 right and #1 left.",31 +4015,Patient with increased shortness of breath of one day duration.,15 +2417, Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,22 +10720,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5985,"Suspected mastoiditis ruled out, right acute otitis media, and severe ear ache resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.",11 +11158,A sample note on Rheumatoid Arthritis,34 +6121,"Austin/akin bunionectomy, right foot. Bunion, right foot. The case states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.",31 +10838,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +1615, Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.,3 +10173,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +710," Cataract, right eye. Phacoemulsification with intraocular lens placement, right eye.",38 +3862," Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.",15 +6628,Excisional biopsy of right cervical lymph node.,16 +1300, An example/template for a routine normal male ROS.,25 +10593,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +6475,Normal child physical exam template.,29 +3354," MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.",22 +10192,Autopsy - Homicide - Blunt force cranial trauma,1 +8878,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +4140,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +5951,"Acute foot or ankle sprain, possible small fracture.",12 +6304,"Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.",6 +7667,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +12046,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +2080, Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,5 +2952," Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis.",14 +3929," Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",5 +8078,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +2666," Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.",22 +9834,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +6674,Sample/template for a normal female multisystem exam,25 +5050,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.,24 +760, Initial evaulation - neck and back pain.,27 +2649," The patient comes for three-week postpartum checkup, complaining of allergies.",35 +9325,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7806,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +10160,This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +9731,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7431,"Specimen labeled ""sesamoid bone left foot"".",19 +6907,Plantar Fascia Injection,28 +7123,The case was referred due to a recent admission for pseudoseizures.,32 +3146," Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",5 +7269,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +11687,Mother states he has been wheezing and coughing.,0 +11398,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +11522,Qualified clinical evaluation report of a patient with back pain.,4 +8852,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +10954,Patient presents for care of suspected rheumatoid arthritis.,34 +4094,"The case is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The case presents for her fetal anatomical survey.",24 +998, Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated.,11 +4815,"Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",10 +10445,Qualified clinical evaluation report of a patient with back pain.,4 +1220," Right shockwave lithotripsy, cystoscopy, and stent removal x2.",38 +4555,A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 +4600,"Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.",23 +8804,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +5726,Common CT Neck template.,11 +12553,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +5924,"An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",12 +10562,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2020," Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.",38 +4519,A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,24 +3750," Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. ",35 +11357,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +10908,Dietary consultation for carbohydrate counting for type I diabetes.,9 +289, Patient in ER with upper respiratory infection,12 +4967,"Patient had some cold symptoms, was treated as bronchitis with antibiotics.",10 +2335," The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",5 +8890,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +4238,Decreased ability to perform daily living activities secondary to right knee surgery.,10 +9056,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +11872,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5575,An example/template for a routine normal female physical exam.,25 +1954," Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.",24 +9693,A sample note on Rheumatoid Arthritis,34 +9032,MRI report Cervical Spine (Chiropractic Specific),4 +2445," CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.",33 +4060,Foul-smelling urine and stomach ache after meals.,14 +10936,Autopsy - Asphyxia due to ligature strangulation.,1 +15, Common description of EGD.,38 +1757, Patient complains of constipation. Has not had BM for two days.,25 +10757,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11300,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +3434, Revision right total knee arthroplasty. Right failed total knee arthroplasty.,38 +8477,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +8186,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +7840,A 23-year-old white female presents with complaint of allergies.,0 +9722,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9778,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11183,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +460, Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. Adenocarcinoma of the prostate.,38 +9184,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +8060,Preop evaluation regarding gastric bypass surgery.,2 +9233,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +2170, Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.,38 +9861,Dietary consultation for gestational diabetes.,9 +10828,Autopsy of a white female who died of acute combined drug intoxication.,1 +6796,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +9320,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +3174, Coccygeal injection,28 +7450,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +4399,Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,35 +8946,Consultation for left foot pain.,4 +3142, Cystopyelogram and laser vaporization of the prostate.,39 +9978,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +3871, MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,33 +5389,"Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",23 +1124, 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. ,3 +3119, Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +11062,Autopsy of a white female who died of acute combined drug intoxication.,1 +6227,"Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.",28 +9286,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11639,Is it BNP or BMP?,19 +9397,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2576," Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",3 +6491,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11898,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +8430,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +11196,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +613," Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.",38 +3387," Pain and swelling in the right foot, peroneal tendon tear.",33 +3555," The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.",22 +4641,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 +7995,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +433, Consultation for an ASCUS Pap smear.,5 +858, Patient coughing up blood and with severe joint pain.,15 +11768,Cause of death - Anoxic Encephalopathy,1 +3205," Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",38 +10845,"Status post brain tumor with removal. The case did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +1364, Overactive bladder with microscopic hematuria.,35 +11221,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +220," Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.",38 +9435,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4586,"Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 +6398,Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +4066,HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 +7697,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +10069,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +9118,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +739," Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +6716,Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 +5398,"The case is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.",12 +7530,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8549,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +2629, CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,22 +1484, Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,27 +9423,Is it BNP or BMP?,19 +5569,"Congestion, tactile temperature.",29 +1119," Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..",5 +1758," Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",23 +3155, Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,27 +986," Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +480," C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.",38 +804, CCTA with Cardiac Function/Calcium Scoring,3 +3131," Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.",38 +12182,A 23-year-old white female presents with complaint of allergies.,0 +8169,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +4814,"Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.",10 +10982,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9469,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10355,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +3200, A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.,15 +3419," Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.",38 +5571,"Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 +2689," Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. ",5 +8189,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 +7199,"Records review. The client developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.",18 +8214,Belly button piercing for insertion of belly button ring.,6 +8441,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +709," Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ",27 +22, A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. ,5 +5792,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +8221,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +5717,The case seeks evaluation for a second opinion concerning cataract extraction.,26 +3700, Right foot series after a foot injury.,31 +1330, KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.,27 +8537,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9026,MRI report Cervical Spine (Chiropractic Specific),4 +8407,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +9531,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4228,Resting Myoview and adenosine Myoview SPECT,33 +12268,Autopsy of a white female who died of acute combined drug intoxication.,1 +10530,Occupational medicine consult with questions-answers and records review.,18 +2501," A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.",5 +8764,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +11425,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +12379,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3843, Thallium stress test for chest pain.,3 +11464,Cause of death - Anoxic Encephalopathy,1 +4930,"Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.",11 +5788,"Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 +3136," Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.",5 +10359,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +2037, Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.,38 +4468,Chiropractic IME with answers to questions from Insurance Company.,20 +1550, Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.,27 +3898," Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability.",38 +2671," Upper endoscopy, patient with dysphagia.",14 +9838,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1160, Patient complains of chest pain - possible esophageal reflux,12 +12482,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1264, Bilateral vasovasostomy surgery sample.,38 +3701," Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.",27 +1750, Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia.,24 +2477, MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,22 +9122,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +1987, Common CT Neck template.,33 +10046,A 23-year-old white female presents with complaint of allergies.,0 +4164,The case is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 +5952,"Acute foot or ankle sprain, possible small fracture.",12 +7240,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +748," Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",15 +1103, Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.,38 +12142,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10440,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +3121," The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",33 +5409,"Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. Cataract, right eye.",26 +10537,Occupational medicine consult with questions-answers and records review.,18 +9715,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +5029,"This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy.",35 +11699,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +8145,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +11511,Autopsy - Asphyxia due to ligature strangulation.,1 +10485,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10739,"Specimen labeled ""sesamoid bone left foot"".",19 +12361,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +12553,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10103,Dietary consultation for diabetes during pregnancy.,9 +5056,"Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 +7741,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +209," Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.",25 +2708," EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.",14 +11449,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +5076,Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular discomfort status post CT scan of the thorax.,16 +7460,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +1718, Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,38 +9643,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8545,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +8825,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +4485,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,22 +3113, Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 +6130,A 66-year-old client who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 +2258, A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,3 +7033,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +7708,Occupational medicine consult with questions-answers and records review.,18 +10133,The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +1937," Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.",24 +4868,"Cataract, nuclear sclerotic, right eye. Phacoemulsification with intraocular lens implantation, right eye.",26 +10812,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +1298, Discharge summary of a patient with depression and high risk behavior.,10 +12349,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5599,"Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.",23 +8734,Evaluation for bariatric surgery.,2 +9314,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +12542,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3663," Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",15 +3888, The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.,5 +8020,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid therapy to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +4965,"Patient had some cold symptoms, was treated as bronchitis with antibiotics.",10 +7346,Work restrictions and disability evaluation,4 +11733,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5476,"Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.",24 +11651,Dietary consultation for diabetes during pregnancy.,9 +10690,Is it BNP or BMP?,19 +4305,"Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.",15 +9326,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8683,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +7315,A sample note on Rheumatoid Arthritis,34 +4411,"Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",23 +2748, A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,22 +6487,The patient continues to suffer from ongoing neck and lower back ache with no recent radicular complaints.,25 +9472,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +11731,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +4305,"Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.",15 +2366, Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction.,3 +6691,"A 7-year-old white male started to complain of ache in his fingers, elbows, and neck. This patient may have had reactive arthritis.",29 +2491," Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.",27 +113," Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 +5156,a pleasant 62-year-old male with cerebral palsy,10 +4923,"Follow up consultation, second opinion, foreskin.",39 +9244,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1996," Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 +8050,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +6270,She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,26 +1161," Brachytherapy, iodine-125 seed implantation, and cystoscopy.",38 +8211,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +6431,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 +79, Lysis of pelvic adhesions. The patient had an 8 cm left ovarian mass. The mass was palpable on physical examination and was tender. She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.,38 +90, Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. ,30 +6352,"Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 +262," Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.",5 +1015, Noncontrast CT head due to seizure disorder.,22 +4804,Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.,22 +7768,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +9621,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9409,A 23-year-old white female presents with complaint of allergies.,0 +2068," Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.",27 +11868,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9866,Dietary consultation for gestational diabetes.,9 +5112,"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.",16 +3475," Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.",3 +4497,Right distal ureteral calculus. The case had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.,39 +10141,"Followup diabetes mellitus, type 1.",13 +1379," Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",16 +6866,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 +12074,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4235,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +3484, Itchy red rash on feet - Tinea Pedis,31 +9282,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +3793," Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction.",3 +9657,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4584,"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.",29 +3780, Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.,27 +11806,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12385,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +5679,"Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",10 +8178,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +6194,"Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",11 +5449,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,16 +6770,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +728, Follow up update on patient with left carotid angioplasty and stent placement.,20 +11594,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +3568, Intensity-modulated radiation therapy simulation note. The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. ,33 +3072," The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",5 +7698,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10353,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +939, A 27-year-old female with a size and date discrepancy.,33 +9865,Dietary consultation for gestational diabetes.,9 +6733,Phacoemulsification with posterior chamber intraocular lens insertion.,26 +7356,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +10446,Qualified clinical evaluation report of a patient with back pain.,4 +3001," Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.",38 +6696,"Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",11 +9971,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +7011,Blepharoplasty procedure,26 +4133,"Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 +763," Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +11075,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +1815, A female for a complete physical and follow up on asthma with allergic rhinitis.,3 +7835,"The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +2600," A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. ",5 +2098, Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.,27 +7242,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +1331, A female with unknown gestational age who presents to the ED after a suicide attempt.,12 +6174,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +3849, A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,15 +12092,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +10005,Chiropractic IME with answers to questions from Insurance Company.,4 +5149,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +7201,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +60, Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,38 +1467," Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.",38 +5930,Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.,32 +5533,A female with unknown gestational age who presents to the ED after a suicide attempt.,12 +3300, One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,5 +2190," Direct inguinal hernia. Rutkow direct inguinal herniorrhaphy. A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. ",38 +3878," Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.",3 +8196,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +10967,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8215,Belly button piercing for insertion of belly button ring.,6 +11546,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3078," Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.",27 +5760,The case with continued problems with her headaches.,25 +7772,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +12013,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +4091,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 +4504,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +2367," White male with onset of chest pain, with history of on and off chest discomfort over the past several days.",38 +5745,Mother states he has been wheezing and coughing.,29 +1903," Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. ",38 +8602,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +4059,Foul-smelling urine and stomach ache after meals.,14 +11308,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +7297,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7421,Dietary consultation for diabetes during pregnancy.,9 +5361,"Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",24 +4136,"Patient with hypertension, dementia, and depression.",15 +2308," C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",38 +1039, MRI Cervical Spine without contrast.,22 +2762," Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.",5 +444," Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.",38 +6461,Consultation for wrist pain.,4 +6112,Right ear ache with drainage - otitis media and otorrhea.,11 +6529,Plantar fascitis/heel spur syndrome. The client was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,31 +8110,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +8783,Dietary consultation for gestational diabetes.,9 +3088," Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.",35 +11926,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.",30 +37," Pressure decubitus, right hip",15 +4321,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 +5826,"Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.",12 +4755,"Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.",28 +12098,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8649,"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +618," Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.",38 +6930,"Sample normal ear, nose, mouth, and throat exam.",25 +824," Plantar fascitis, left foot. Partial plantar fasciotomy.",31 +4661,"Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.",23 +11842,A sample note on Rheumatoid Arthritis,34 +12501,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +7628,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6502,"Acute renal failure, suspected, likely due to multi-organ system failure syndrome.",21 +12276,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +2849," Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.",15 +2716," Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",38 +5260,"This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.",10 +5505,A case with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,16 +6050,"Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",26 +8535,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +11555,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +12057,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +6267,Pain management sample progress note.,28 +359, Routine colorectal cancer screening. He occasionally gets some loose stools. ,16 +4820,"Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +11254,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +12327,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +188," The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.",3 +7014,Dietary consultation for carbohydrate counting for type I diabetes.,9 +11669,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +12530,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +6088,Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.,31 +12102,Autopsy - Asphyxia due to ligature strangulation.,1 +11350,Chiropractic IME with answers to questions from Insurance Company.,18 +2593, Patient presents for a colostomy reversal as well as repair of an incisional hernia. ,14 +5000,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +9582,Autopsy - Asphyxia due to ligature strangulation.,1 +12096,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +7808,Follow up update on client with left carotid angioplasty and stent placement.,20 +8606,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +5653,A white female with a history of fevers.,10 +5168,"Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",39 +1202," Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",5 +54, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,11 +7045,Nephrology office visit for followup of microscopic hematuria.,25 +9709,A sample note on Rheumatoid Arthritis,34 +7648,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12045,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +6150,"The patient has had abdominal discomfort associated with a 30-pound weight loss and then developed jaundice. He had epigastric discomfort and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.",10 +3704," 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.",15 +9890,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7542,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7262,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4163,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +2898," Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.",3 +11453,Consultation for wrist pain.,4 +10400,Chronic snoring in children,36 +7754,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +4912,The case returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. Concerning slow ongoing rise in PSA.,39 +1011, Psychosocial Evaluation of patient before kidney transplant.,21 +1199, Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +3814, Cystopyelogram and laser vaporization of the prostate.,38 +11739,Autopsy of a white female who died of acute combined drug intoxication.,1 +6738,"A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the determination of intracranial bleeding.",12 +4230,Sample progress note - Gen Med.,15 +1993, Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,38 +3315, Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. ,14 +686, Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,24 +6241,"Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.",11 +5883,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +8020,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid therapy to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 +844," Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.",11 +12436,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10932,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4168,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +4577,Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.,29 +12438,Autopsy - Homicide - Blunt force cranial trauma,1 +2595," A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.",15 +440, Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.,3 +2777, Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,27 +2453," 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.",38 +214," Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",38 +5842,"Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.",23 +8666,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +12157,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4432,Newly diagnosed head and neck cancer. The client was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 +4242,"The case has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",32 +3997, Repair of bilateral cleft of the palate with vomer flaps.,11 +7230,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11540,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +285," 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. ",22 +10444,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8071,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +4188,Patient with intermittent episodes of severe nausea and abdominal pain.,15 +9136,Autopsy of a white female who died of acute combined drug intoxication.,1 +11771,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +3891, Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.,38 +3481," The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. ",5 +1083, General Medicine SOAP note.,35 +6375,Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,26 +1951," Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",38 +1964, Neurologic examination sample. ,35 +7848,Work restrictions and disability evaluation,18 +5550,"Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",31 +1444," Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",38 +7225,Is it BNP or BMP?,19 +11813,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2601," Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.",27 +7221,A 23-year-old white female presents with complaint of allergies.,0 +784, Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.,3 +5496,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +3723," Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.",27 +687, She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,15 +1289," Woman with adult hydrocephalus, routine evaluation. ",22 +11662,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +4070,Normal Circumcision,39 +3119, Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +293," Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",35 +5597,"Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.",23 +2741, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,35 +3064, 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.,3 +2625," Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue",5 +3360," The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.",5 +9419,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6183,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +11233,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +10216,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +1000," Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.",24 +6495,"CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.",21 +9078,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +12080,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +4972,Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 +10248,Significant ache in left lower jaw.,7 +191, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,3 +11418,Autopsy of a white female who died of acute combined drug intoxication.,1 +2565, Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy. ,11 +1816, Pain and swelling in the right foot.,31 +7491,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +7672,"Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 +8555,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +4417,A 2-month-old female with 1-week history of congestion and fever x2 days.,29 +8884,"Ankle sprain, left ankle. The client tripped over her dog toy and fell with her left foot inverted. The client states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the client continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month.",30 +4780,The case was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.,35 +9412,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +12228,"Specimen labeled ""sesamoid bone left foot"".",19 +9738,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +5140,"Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.",39 +11006,A 23-year-old white female presents with complaint of allergies.,0 +5082,Right radical nephrectomy and assisted laparoscopic approach.,21 +2822, A middle-aged female with memory loss.,33 +4264,A 65-year-old man with chronic prostatitis returns for recheck.,35 +7389,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +5868,Template for History and Physical for a newborn.,25 +5691,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 +2707," Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.",39 +1737, Headache and diplopia.,22 +7016,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,26 +11818,Patient presents for care of suspected rheumatoid arthritis.,34 +3056," Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.",38 +9207,Evaluation for chronic discomfort program,4 +11923,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +881, Standard Laparoscopic Cholecystectomy Operative Note.,14 +36, MRI Cervical Spine without contrast.,33 +1876, Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,27 +8127,Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,6 +3712, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,3 +5008,"The client is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",11 +2086, Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings),33 +4684,AP abdomen and ultrasound of kidney.,21 +10154,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +1117, Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,24 +2802," A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.",22 +4358,"Open reduction, nasal fracture with nasal septoplasty.",11 +3139, Flexible sigmoidoscopy due to rectal bleeding.,38 +10538,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +10821,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +7706,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 +4908,"Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",16 +7102,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +2444, Completion thyroidectomy with limited right paratracheal node dissection.,13 +6469,"Psychiatric evaluation for ADHD, combined type.",32 +1283, Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. ,38 +5362,"Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",24 +10834,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +1592," Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.",3 +5908,"Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",21 +405," This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. ",10 +5388,"Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.",23 +6997,The case needs refills on her Xanax,25 +2592," Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +4185,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",35 +1755," Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. ",38 +8750,Occupational medicine consult with questions-answers.,18 +9312,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +11175,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4502,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +660, Pain management for post-laminectomy low back syndrome and radiculopathy. ,27 +9402,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +2252, Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. ,28 +4621,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +6906,Prostate Brachytherapy - Prostate I-125 Implantation,16 +11252,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +3961," A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study. ",22 +11069,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6873,"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.",23 +6095,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +6415,Consult for laparoscopic gastric bypass.,2 +12493,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +2820," A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. ",3 +12002,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +1233, Complaint of mood swings and tearfulness.,5 +1373," This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. ",22 +11389,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +9606,Patient presents for care of suspected rheumatoid arthritis.,34 +6567,Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 +10102,Dietary consultation for diabetes during pregnancy.,9 +515," Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",26 +4786,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +2990, Patient with swelling of lips and dysphagia and Arthritis.,15 +4953,Vitrectomy under local anesthesia.,26 +7075,Right foot series after a foot injury.,31 +6269,She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,26 +4613,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",10 +8556,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +11041,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7244,Autopsy - Homicide - Blunt force cranial trauma,1 +7241,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +457," Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.",16 +3914," Primary low-transverse C-section. Postdates pregnancy, failure to progress, meconium stained amniotic fluid.",24 +8793,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +8761,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +3466," Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",5 +12252,Autopsy - Homicide - Blunt force cranial trauma,1 +864, Right radical nephrectomy and assisted laparoscopic approach.,21 +8102,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +1853, Diagnostic Mammogram and ultrasound of the breast.,33 +4706,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +1444," Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.",38 +747, Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,38 +6779,Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,23 +11090,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10450,Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent clinical evaluation.,18 +5546,Marked right hydronephrosis without hydruria.,21 +4311,"Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 +4737,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",10 +6235,The client has a possibly torsion detorsion versus other acute testicular problem.,12 +2221," CT abdomen and pelvis without contrast, stone protocol, reconstruction.",33 +3988," Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.",38 +7177,Vaginal discharge with a foul odor.,12 +9487,A sample note on Rheumatoid Arthritis,34 +2472," Creation of AV fistula, left wrist in the anatomic snuffbox.",38 +5613,"Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.",31 +7656,Patient presents for care of suspected rheumatoid arthritis.,34 +2568," Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.",32 +6411,Intensity-modulated radiation therapy simulation note. The client will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.,16 +3739, Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.,15 +9852,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +2184, Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. ,28 +7833,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 +5311,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 +10488,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5640,"Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.",16 +7090,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +7997,Autopsy - Homicide - Blunt force cranial trauma,1 +8339,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +10624,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8833,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +7523,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11656,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9123,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +4884,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",10 +10282,The client is status post C3-C4 anterior cervical discectomy and fusion.,30 +4846,Excision of penile skin bridges about 2 cm in size.,39 +6071,The patient's main complaint is vertigo. The case is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +800," Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. ",38 +2054, Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage. The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. ,38 +7179,Vaginal discharge with a foul odor.,12 +5487,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +911," Melena and solitary erosion over a fold at the GE junction, gastric side.",38 +9348,Patient presents for therapy of suspected rheumatoid arthritis.,34 +7445,A sample note on Rheumatoid Arthritis,34 +7237,Mother states he has been wheezing and coughing.,0 +1369, Progressive loss of color vision OD.,22 +11494,Initial evaulation - neck and back pain.,4 +383, Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,26 +2632," Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.",38 +8965,Mother states he has been wheezing and coughing.,0 +6794,"Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.",26 +6470,"Psychiatric evaluation for ADHD, combined type.",32 +3488," Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",38 +11313,Dietary consultation for diabetes during pregnancy.,9 +3064, 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.,3 +6673,Sample/template for a normal female multisystem exam,25 +580, Patient in with mom for possible ear infection.,15 +3081, Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).,38 +3257, Blepharoplasty with direct brow repair.,38 +6500,"CT abdomen and pelvis without contrast, stone protocol, reconstruction.",21 +2125, A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,12 +9179,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +2255," Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.",27 +638," Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",38 +602, Consult and Spinal fluid evaluation in a 15-day-old,29 +11661,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +2542, Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.,38 +10665,Evaluation for bariatric surgery.,2 +2829," History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).",5 +2657," Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.",38 +9699,A sample note on Rheumatoid Arthritis,34 +9938,"Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.",7 +9519,Autopsy of a white female who died of acute combined drug intoxication.,1 +8043,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 +8079,"Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.",7 +3462," T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.",5 +8230,Qualified healthcare evaluation report of a patient with back pain.,18 +10453,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +3634, Right radical nephrectomy and assisted laparoscopic approach.,38 +5206,"Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.",39 +4054,Bilateral Myringotomy with placement of PE tubes,11 +10271,Consult for laparoscopic gastric bypass.,2 +8824,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +1783," Severe tonsillitis, palatal cellulitis, and inability to swallow.",11 +1817," Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",15 +19, 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.,3 +6951,"Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 +3534, Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,5 +6182,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +6689,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +10195,The case underwent an overnight polysomnogram.,36 +3994, 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.,5 +10814,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +6321,Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 +10031,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +9698,A sample note on Rheumatoid Arthritis,34 +5766,Evaluation for right L4 selective nerve root block.,28 +6307,"Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.",7 +8420,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +6829,13 years old complaining about severe ear ache - Chronic otitis media.,11 +10761,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +4532,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",35 +11508,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +10886,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +10372,Qualified clinical evaluation report of a patient with back pain.,18 +975," Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.",31 +9630,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6229,"Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.",28 +5197,"Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",26 +2015," Irritable baby, 6-week-old, with fever for approximately 24 hours.",5 +8606,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +5094,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",16 +5059,Burr hole and insertion of external ventricular drain catheter.,23 +2030, Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,38 +1510," Cystoscopy, cryosurgical ablation of the prostate.",38 +1860," Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.",5 +11256,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +12496,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6334,"Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",11 +70, Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +10213,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +4613,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",10 +3563," A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.",10 +10726,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +8893,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +9907,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6847,Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe.,28 +5355,"Cystoscopy, cryosurgical ablation of the prostate.",39 +12531,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8494,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +7681,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7883,Occupational medicine consult with questions-answers and records review.,18 +1524," Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",38 +770, Left shoulder pain. Evaluate for rotator cuff tear.,27 +6054,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent identification of urinary tract infection on outpatient treatment with nitrofurantoin.,10 +10618,Chiropractic IME with answers to questions from Insurance Company.,4 +6205,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 +11322,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +2813, Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +5084,Right radical nephrectomy and assisted laparoscopic approach.,21 +1549," Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.",39 +6010,"Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",12 +7357,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +6742,Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 +9069,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +12294,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +8795,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +6200,A well-child check with concern of some spitting up quite a bit.,29 +10451,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 +4059,Foul-smelling urine and stomach ache after meals.,14 +7712,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +1491," Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",27 +12044,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +2483," Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.",15 +10003,Chiropractic IME with answers to questions from Insurance Company.,4 +3732," Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.",38 +5527,"Well-child check sports physical - Well child asthma with good control, allergic rhinitis.",29 +5785,Chiropractic IME with answers to questions from Insurance Company.,18 +10258,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 +8179,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 +1983, Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.,38 +4301,Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.,11 +11664,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +10091,Occupational medicine consult with questions-answers and records review.,18 +9087,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +11631,Dietary consultation for gestational diabetes.,9 +4816,Chiropractic IME with answers to questions from Insurance Company.,4 +910," Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.",27 +12648,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4907,"Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.",39 +6604,Tonsillectomy. Chronic tonsillitis.,11 +6255,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +219, Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 +1375, Primary low segment cesarean section.,24 +4803,"Creation of AV fistula, left wrist in the anatomic snuffbox.",21 +828, Laparoscopic appendectomy. Acute appendicitis.,38 +6926,"Lower quadrant discomfort with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 +12634,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +277, Left elbow manipulation and hardware removal of left elbow.,27 +5851,Sleep study - case with symptoms of obstructive sleep apnea with snoring.,36 +12184,A 23-year-old white female presents with complaint of allergies.,0 +794, Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 +7053,Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 +5248,Dietary consultation for gestational diabetes.,9 +9555,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8101,Occupational medicine consult with questions-answers and records review.,18 +6473,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +3234," Onychomycosis present, #1 right and #1 left.",31 +4036,"Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.",24 +10442,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12551,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9193,Consult for laparoscopic gastric bypass.,2 +10284,Occupational medicine consult with questions-answers and records review.,18 +3977," Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.",24 +2075," Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.",38 +9989,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +11133,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3133, Psychiatric consultation for management of pain medications.,5 +9860,Dietary consultation for gestational diabetes.,9 +10909,Dietary consultation for carbohydrate counting for type I diabetes.,9 +9400,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9556,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +4702,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 +2989, Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,22 +544," Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. +",38 +7156,Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.,25 +11017,Is it BNP or BMP?,19 +5316,"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.",25 +7898,Dietary consultation for diabetes during pregnancy.,9 +321," Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. +",3 +12327,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9964,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +3860," Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.",35 +5747,One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 +4085,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +12582,Is it BNP or BMP?,19 +10494,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +12590,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +12015,"Left thyroid mass. Left total thyroid lumpectomy. The case with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +6960,"Gangrene osteomyelitis, right second toe. The case is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The case has history of previous right foot infection requiring first ray resection.",31 +2508, Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,33 +4089,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 +8077,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +3424," Severe tonsillitis, palatal cellulitis, and inability to swallow.",5 +9780,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +5058,Burr hole and insertion of external ventricular drain catheter.,23 +2362, Colonoscopy with random biopsies and culture.,38 +6810,"Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,",8 +7954,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 +3491, Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. ,38 +5270,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 +6587,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +6802,"9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.",20 +7688,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +3296," Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. ",27 +4111,Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,11 +5964,Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,21 +6631,"Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 +2662, A 75-year-old female comes in with concerns of having a stroke.,35 +4142,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +3140," Fiberoptic bronchoscopy with endobronchial biopsies. A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.",3 +4357,"A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.",14 +10095,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +6184,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +5769,Blepharoplasty procedure,6 +9166,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +2038, Normal Circumcision,38 +3899, Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,14 +5483,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +1280, Laparoscopic-assisted vaginal hysterectomy. Abnormal uterine bleeding. Uterine fibroids.,38 +4552,An example/template for a routine normal male physical exam.,25 +10042,"The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +5963,Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,21 +7281,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +6125,Trabeculectomy with mitomycin C - Sample/Template.,26 +640," Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started.",38 +5564,"Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.",39 +9513,Autopsy of a white female who died of acute combined drug intoxication.,1 +11472,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 +6209,4-day-old with hyperbilirubinemia and heart murmur.,29 +3412," Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 +4413,Patient in ER due to colostomy failure - bowel obstruction.,14 +3771, Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia.,3 +9617,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +7784,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +6739,"A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the identification of intracranial bleeding.",12 +11508,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1197," Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.",38 +4116,"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 +10912,Dietary consultation for carbohydrate counting for type I diabetes.,9 +3306, Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,27 +2932," Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.",38 +8326,Bilateral reduction mammoplasty for bilateral macromastia,6 +4025,Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,23 +11085,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9257,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +3542, Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. ,15 +8990,Autopsy - Homicide - Blunt force cranial trauma,1 +5095,"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.",16 +7345,Work restrictions and disability evaluation,4 +5420,Patient referred for narrow angles and possible associated glaucoma.,26 +9886,Mother states he has been wheezing and coughing.,0 +9289,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +11070,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +6815,The client is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness.,11 +7473,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +5586,Pediatric Gastroenterology - History of gagging.,29 +1030," Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.",3 +2374," Adenotonsillectomy, primary, patient under age 12.",11 +9353,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3008, Qualified medical evaluation report of a patient with back pain.,18 +12481,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +12221,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +3972," Pars plana vitrectomy, membrane peel, 23-gauge, right eye.",38 +4022,Work restrictions and disability evaluation,4 +133," 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",15 +11037,Mother states he has been wheezing and coughing.,0 +9102,Preop evaluation regarding gastric bypass surgery.,2 +172," Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.",33 +419," Normal physical exam template. Well developed, well nourished, in no acute distress.",5 +6364,Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,11 +11971,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +5816,Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,10 +6400,Punch biopsy of right upper chest skin lesion.,8 +11745,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +5839,Patient complains of constipation. Has not had BM for two days.,25 +9557,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 +5337,Psychiatric Consultation of case with dementia.,32 +6382,"Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma.",21 +4163,Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +2607, Patient today with ongoing issues with diabetic control.,15 +4201,"Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 +12006,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +670, 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.,33 +1111, MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,22 +4788,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +2123, A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.,5 +10223,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 +10713,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +1659," Closure of rectovaginal fistula, transperineal approach",38 +7825,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +8403,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3921, Elevated cholesterol and is on medication to lower it.,9 +9338,Elevated cholesterol and is on medication to lower it.,9 +8196,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +6294,Nephrology office visit for followup of CKD.,21 +5604,"Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.",26 +8444,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +9437,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4356,"A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.",14 +7738,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +8030,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 +2705," Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",3 +11867,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +357," An 85-year-old female with diarrhea, vomiting, and abdominal pain.",15 +2700," Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.",24 +11834,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +9885,Mother states he has been wheezing and coughing.,0 +6103,"Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +1232, Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,38 +3428, Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,22 +11480,Qualified medical evaluation report of a client with back pain.,18 +10096,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +526," A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.",30 +5214,"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The case was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.",16 +730, Knee injection,28 +2169," Left scrotal exploration with detorsion. Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.",38 +10505,Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.,30 +1698, Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,5 +47, Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +11608,A 23-year-old white female presents with complaint of allergies.,0 +4195,Procedure note on Keller Bunionectomy,31 +2654, The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,25 +6282,"She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.",28 +8090,Autopsy of a white female who died of acute combined drug intoxication.,1 +787," The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",11 +9582,Autopsy - Asphyxia due to ligature strangulation.,1 +2588, Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.,12 +6011,MRI report Cervical Spine (Chiropractic Specific),4 +1059, Headache and diplopia.,5 +10172,Consultation for left foot pain.,4 +6917,Incision and drainage of right buccal space abscess and teeth extraction.,7 +6260,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 +4560,Falls at home. Anxiety and depression. The case had been increasingly anxious and freely admitted that she was depressed at home.,22 +10147,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 +10813,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +11279,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +11377,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +5651,A white female with a history of fevers.,10 +6617,Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 +2323," 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.",27 +2856, Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. ,27 +8298,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 +6396,Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +11895,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +6678,Acromioclavicular joint injection,28 +1700, Consultation for left foot pain.,4 +4301,Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.,11 +8317,Patient being referred for evaluation of glaucoma.,20 +3072," The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.",5 +6634,The client is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,29 +2837," Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.",38 +12176,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4199,Diagnosis of benign rolandic epilepsy.,22 +9536,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +6360,Repair of ruptured globe involving posterior sclera - Sample/Template.,26 +6521,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +5378,Difficulty with both distance vision and with fine print at near.,26 +7899,Dietary consultation for diabetes during pregnancy.,9 +10224,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +7934,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +449, She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.,32 +758, Epigastric herniorrhaphy. Epigastric hernia.,14 +4405,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +9245,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7040,"Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 +5311,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 +1534, Laparoscopic bilateral tubal ligation with Falope rings.,38 +1506," Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.",27 +9220,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +12583,Is it BNP or BMP?,19 +10580,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10119,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +3104," Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.",14 +8685,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +3925, Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,38 +11959,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +6978,Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,28 +6649,Newborn circumcision. The penile foreskin was removed using Gomco.,29 +9629,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +6793,"Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.",26 +1654," Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.",15 +363," Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain",35 +201, Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. ,38 +10467,Work restrictions and disability evaluation,4 +587," Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +3121," The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The patient presents for her fetal anatomical survey. ",33 +9608,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5179,"Left flank pain, ureteral stone.",39 +7005,"Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.",6 +7352,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +5323,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +4186,"Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",35 +1733, Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,10 +1844," A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.",39 +10241,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 +12278,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +2489, Migraine headache - The patient was seen in the urgent care.,12 +695," Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction. ",11 +10891,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +10651,A 23-year-old white female presents with complaint of allergies.,0 +2298, A 3-month well-child check. ,5 +2818, The patient is in complaining of headaches and dizzy spells.,35 +2537," First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +912, Consultation for wrist pain.,5 +6408,13 years old complaining about severe ear ache - Chronic otitis media.,29 +6581,"Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 +503," Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.",27 +5276,Pediatric Gastroenterology - Rectal Bleeding Consult.,29 +4721,Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.,21 +2439," Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.",11 +8749,Occupational medicine consult with questions-answers.,18 +6932,"Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",31 +6528,Plantar fascitis/heel spur syndrome. The case was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,31 +4591,Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,26 +3932," Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.",38 +12595,Mother states he has been wheezing and coughing.,0 +9753,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +10138,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +10980,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10335,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +5402,An example of a physical exam,25 +11930,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the case to achieve hands-free voicing.,37 +4922,Frontal and lateral views of the hip and pelvis.,29 +11261,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +846, Burr hole and insertion of external ventricular drain catheter.,23 +6390,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",16 +5882,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +5995,A 21-channel digital electroencephalogram was performed on a client in the awake state.,36 +4144,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",10 +8172,"Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 +648," 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.",39 +8539,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +847," Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.",14 +3480, Incision and drainage (I&D) of buttock abscess. ,38 +6422,An example normal physical exam,25 +10619,Chiropractic IME with answers to questions from Insurance Company.,4 +8658,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 +11836,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +10941,Autopsy - Asphyxia due to ligature strangulation.,1 +11400,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +4730,A sample note on Cataract,26 +9240,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +4835,"Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 +8210,A 19-year-old right-handed male injured in a motor vehicle accident.,20 +9031,MRI report Cervical Spine (Chiropractic Specific),4 +2139, Pulmonary Function Test in a patient with smoking history.,3 +12252,Autopsy - Homicide - Blunt force cranial trauma,1 +6826,"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs",23 +8918,"Specimen labeled ""sesamoid bone left foot"".",19 +3656, Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,21 +10121,"Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.",6 +2609," Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy",38 +10875,Cause of death - Anoxic Encephalopathy,1 +8192,"Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.",8 +11757,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10007,Incision and drainage (I&D) of buttock abscess.,8 +12495,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1363, Colonoscopy to evaluate prior history of neoplastic polyps.,38 +7562,A 23-year-old white female presents with complaint of allergies.,0 +6292,"Adenotonsillectomy, primary, client under age 12.",11 +7391,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +5181,"Cystoscopy, cystocele repair, BioArc midurethral sling.",39 +2916, Initial clinic visit for foreign body in left eye.,5 +3851, Left knee arthroscopy with lateral capsular release.,38 +4793,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +3394, Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery,5 +5347,Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.,11 +959, Transesophageal echocardiogram and direct current cardioversion.,33 +1488, MRI Brain & T-spine - Demyelinating disease.,22 +1692, Chiropractic IME with answers to questions from Insurance Company.,18 +2729, Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,38 +2137, Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,38 +6202,A well-child check with concern of some spitting up quite a bit.,29 +822, 1-year well child check.,5 +6406,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",8 +9601,Patient presents for therapy of suspected rheumatoid arthritis.,34 +7624,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +718," Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.",6 +11011,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +9422,Is it BNP or BMP?,19 +6541,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",32 +7745,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +888, Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed,38 +996," Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. ",38 +5748,One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 +1365, Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,38 +154," New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. ",27 +8769,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +9386,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10614,Chiropractic IME with answers to questions from Insurance Company.,4 +7651,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5044,Psychiatric Assessment of a case with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 +7098,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 +12415,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +1887, Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,33 +3619," Nausea, vomiting, diarrhea, and fever.",15 +11933,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +3628, Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +12333,A sample note on Rheumatoid Arthritis,34 +2961, The patient had undergone mitral valve repair about seven days ago. ,3 +9990,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back discomfort radiating into the right leg.",30 +1225, Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +10352,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +5700,A 5-month-old boy brought by his parents because of 2 days of cough.,29 +12385,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +8888,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +69, Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.,38 +6279,"Acute foot or ankle sprain, possible small fracture.",31 +9719,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +1840," Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.",10 +2382," The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. ",24 +9024,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +940," Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +6281,"She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.",28 +6425,"Psychiatric consultation has been requested as the case has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.",32 +5349,"Pain and swelling in the right foot, peroneal tendon tear.",31 +7734,Chiropractic IME with answers to questions from Insurance Company.,20 +2174, Bronchoscopy. Atelectasis and mucous plugging.,3 +674," Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",12 +9757,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +3396, 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. ,5 +4888,Transforaminal epidural steroid block with fluoroscopy.,28 +5497,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9462,Mother states he has been wheezing and coughing.,0 +2344, A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,15 +1118," Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. ",27 +2618, Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,5 +11002,A 23-year-old white female presents with complaint of allergies.,0 +12309,Patient presents for care of suspected rheumatoid arthritis.,34 +24, CT Brain: Midbrain hemangioma,33 +3587, Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,26 +652," Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.",38 +1112, Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. ,38 +11815,Patient presents for care of suspected rheumatoid arthritis.,34 +11533,Work restrictions and disability evaluation,4 +7628,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6680,Acromioclavicular joint injection,28 +3276, Psychological Testing for ADHD,32 +9953,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +12590,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +9380,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2993," Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.",3 +11420,Autopsy of a white female who died of acute combined drug intoxication.,1 +7426,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9858,Dietary consultation for gestational diabetes.,9 +5235,Single frontal view of the chest. Respiratory distress. The client has a history of malrotation.,29 +2603," The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. ",3 +11809,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4825,A 31-year-old white female admitted to the hospital with pelvic ache and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 +57," Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.",27 +9697,A sample note on Rheumatoid Arthritis,34 +2353," Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.",38 +10416,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 +4265,A 65-year-old man with chronic prostatitis returns for recheck.,35 +4172,Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.,10 +3427," Request for consultation to evaluate stomatitis, possibly methotrexate related.",5 +5979,"Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.",10 +5241,Psychosocial Evaluation of client before kidney transplant.,21 +7420,Dietary consultation for diabetes during pregnancy.,9 +4669,"The client noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",39 +11275,Evaluation for bariatric surgery.,2 +6116,She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 +11413,Consult for laparoscopic gastric bypass.,2 +1179, Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.,38 +1719," Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ",30 +1239," Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. ",38 +9168,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +11584,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +6101,"Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.",28 +4131,"Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 +9086,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +8714,A 23-year-old white female presents with complaint of allergies.,0 +3595, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,38 +11210,Chiropractic IME with answers to questions from Insurance Company.,20 +3795, Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,26 +12344,Work restrictions and disability evaluation,4 +10183,"Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.",30 +7739,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +3510," Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.",5 +6706,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +877, Pain and swelling in the right foot.,33 +8788,Is it BNP or BMP?,19 +10081,Is it BNP or BMP?,19 +4719,This case has reoccurring ingrown infected toenails.,31 +11544,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10085,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +6251,Status post cadaveric kidney transplant with stable function.,21 +1319, Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,29 +1465, Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,25 +5315,Penile injury and continuous bleeding from a penile laceration.,12 +3610, Sample/template for a normal male multisystem exam.,25 +2620," Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. ",5 +2186, Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage. ,27 +12316,Patient presents for therapy of suspected rheumatoid arthritis.,34 +9745,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9366,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +2465," Excision of soft tissue mass, right foot. The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.",38 +11212,Chiropractic IME with answers to questions from Insurance Company.,20 +4692,Patient with a long history of depression and attention deficits.,32 +1957, A white female presents for exam and Pap.,5 +10038,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +2281, Acute cholecystitis. Laparoscopic cholecystectomy. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia.,14 +11396,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +9089,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +10437,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +6800,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",31 +7907,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +6398,Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 +1839, The patient underwent an overnight polysomnogram.,36 +7304,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +3592, Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,14 +12167,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8805,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +5910,The client underwent an overnight polysomnogram.,36 +1740," Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.",3 +8406,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +2543," 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. ",5 +9940,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 +3496," Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.",35 +8534,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 +5339,Psychiatric Consultation of case with dementia.,32 +11989,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +2835, Discharge summary of a patient with mood swings and oppositional and defiant behavior.,32 +9388,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +708," Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",27 +11084,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +9259,Dietary consultation for carbohydrate counting for type I diabetes.,9 +31, HCT for memory loss and for calcification of basal ganglia (globus pallidi).,33 +4439,"Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 +5368,Fractional dilatation and curettage,24 +192," Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.",38 +4647,"CT abdomen without contrast and pelvis without contrast, reconstruction.",21 +11761,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11287,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +9457,Mother states he has been wheezing and coughing.,0 +4055,Bilateral Myringotomy with placement of PE tubes,11 +9612,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +9401,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +716, Holter Monitor Report,3 +11167,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +11409,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +2530, Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular pain status post CT scan of the thorax.,35 +261," Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.",27 +7093,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +1749, Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,3 +2392, Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.,38 +823, Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.,3 +1311," Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",14 +2325, Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,33 +10608,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +10605,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +3904," Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.",38 +8304,Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.,6 +8498,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +9581,Autopsy - Asphyxia due to ligature strangulation.,1 +11767,Cause of death - Anoxic Encephalopathy,1 +3386," Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye. Uncontrolled open angle glaucoma and conjunctival scarring, left eye. ",38 +6643,"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +4428,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,33 +4694,"Cerebrovascular accident (CVA). The case presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.",12 +980, Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,24 +9897,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +191, Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,3 +8572,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +3159," Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.",24 +9993,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +12447,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +11097,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +12378,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4454,"Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past clinical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.",22 +10034,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +7867,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +10670,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4207,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,15 +10884,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +8925,"Specimen labeled ""sesamoid bone left foot"".",19 +9631,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +2033, Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,38 +8807,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +109," Type 1 diabetes mellitus, insulin pump requiring. Chronic kidney disease, stage III. Sweet syndrome, hypertension, and dyslipidemia.",35 +4177,Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient clinical therapy.,11 +7094,Bilateral reduction mammoplasty for bilateral macromastia,6 +12321,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +10723,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +160, The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,22 +2590, Encephalopathy related to normal-pressure hydrocephalus.,30 +9096,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +7088,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +1343, Left lower lobectomy.,3 +4439,"Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 +7549,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9881,Mother states he has been wheezing and coughing.,0 +11752,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +12084,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +8721,Work restrictions and disability evaluation,18 +12024,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +6472,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +6535,"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.",21 +5969,Ophthalmology followup visit note.,26 +5401,An example of a physical exam,25 +498, Encephalopathy related to normal-pressure hydrocephalus.,5 +466," Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 +7181,Diagnosis of bulbar cerebral palsy and hypotonia.,20 +3952, This patient has reoccurring ingrown infected toenails.,35 +5516,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 +6769,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 +6464,Nephrology Consultation - Patient with renal failure.,21 +12377,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +10869,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +3578, Consultation for evaluation of thrombocytopenia.,5 +3129, Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,27 +10707,Dietary consultation for diabetes during pregnancy.,9 +8944,Chiropractic IME with answers to questions from Insurance Company.,18 +3785, Superior labrum anterior and posterior lesion repair.,27 +7298,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +9482,Autopsy - Homicide - Blunt force cranial trauma,1 +6559,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,6 +11892,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +11187,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +9121,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +9628,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +769," The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 +9073,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +10623,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11148,A sample note on Rheumatoid Arthritis,34 +9183,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +2339, Flexible bronchoscopy to evaluate the airway (chronic wheezing).,38 +1667, Evaluation for right L4 selective nerve root block.,28 +11465,Cause of death - Anoxic Encephalopathy,1 +4649,CT Abdomen and Pelvis with contrast,21 +4482,Esophagogastroduodenoscopy and colonoscopy with polypectomy,14 +407, Direct right inguinal hernia. Marlex repair of right inguinal hernia.,38 +11803,Autopsy - Asphyxia due to ligature strangulation.,1 +10026,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +11653,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +6315,Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 +5960,Lower lid blepharoplasty.,26 +5998,Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,16 +5734,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",6 +3719," Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.",24 +7973,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +2079," Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.",33 +4998,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +2838," Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.",39 +5945,A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,16 +1899," Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +3242, Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,22 +5192,"Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The client works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.",31 +2884," Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.",3 +6429,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 +581, This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,33 +5898,"The client is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.",10 +8059,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 +5885,"Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.",23 +416, Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 +1222, A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,16 +1982, Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,15 +6570,Psychiatric consultation of case with lethargy.,32 +6140,"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",21 +10432,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +1579, Occupational medicine consult with questions-answers and records review.,5 +271, Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.,16 +9066,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +3700, Right foot series after a foot injury.,31 +10136,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 +1412," Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.",27 +5161,"Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.",25 +6254,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +12549,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3184, A 16-year-old male with Q-fever endocarditis.,35 +9098,Preop evaluation regarding gastric bypass surgery.,2 +4443,4-day-old with hyperbilirubinemia and heart murmur.,12 +8836,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 +8425,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +2969," This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. ",3 +797, Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,38 +5024,"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.",24 +2918," Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.",3 +6171,"A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.",10 +9887,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +7361,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +12400,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +1533, Pediatric Gastroenterology - Rectal Bleeding Consult.,5 +1723, Cadaveric renal transplant to right pelvis - endstage renal disease.,21 +7602,Autopsy - Homicide - Blunt force cranial trauma,1 +8550,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +8463,Occupational medicine consult with questions-answers and records review.,18 +9846,A 23-year-old white female presents with complaint of allergies.,0 +4594,"A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.",10 +4181,Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,39 +4712,"Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.",10 +2401, This is a middle-aged female with two month history of low back pain and leg pain.,27 +9954,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +10037,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +2734, MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,33 +6410,13 years old complaining about severe ear discomfort - Chronic otitis media.,29 +3642," Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.",38 +5174,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,10 +4978,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 +2988, Prostate Brachytherapy - Prostate I-125 Implantation,39 +4742,"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient therapy and increased mood lability.",32 +5956,"Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.",29 +2917, Left Iliopsoas hematoma. Gait difficulty.,22 +2209, A white female with a history of fevers.,15 +3181," Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. ",27 +10326,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +11706,Autopsy - Homicide - Blunt force cranial trauma,1 +7360,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +4636,Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,11 +9231,Chiropractic Evaluation for neck and low back ache following a car accident.,4 +9681,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1286," Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.",28 +623, Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,21 +9065,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +5036,Psychiatric Consultation of client with anxiety.,32 +4389,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +7334,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4914,Right orchiopexy and right inguinal hernia repair.,39 +11027,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +2215, Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 +3089," Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.",21 +10792,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +11030,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +1669, Blepharoplasty procedure,6 +5425,"Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to healthcare therapy, severe anemia, and fibroid uterus.",10 +6490,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +3433, Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.,38 +9228,Cause of death - Anoxic Encephalopathy,1 +2562," Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision.",3 +5102,A 23-year-old white female presents with complaint of allergies.,0 +10671,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +4016,Patient with increased shortness of breath of one day duration.,15 +2767," Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.",39 +1386," Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.",27 +1862, Left lower extremity venous Doppler ultrasound,3 +1296," The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",5 +5359,Nephrology office visit for followup of CKD.,25 +6330,"Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.",26 +6568,Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.,32 +6605,Tonsillectomy. Chronic tonsillitis.,11 +10325,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +5789,Consultation for left foot pain.,4 +4665,"Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.",26 +6725,"The client with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +2304, Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +11820,Patient presents for therapy of suspected rheumatoid arthritis.,34 +4567,"The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent identification of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.",14 +8027,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +5413,This client was seen in clinic for a school physical.,29 +5581,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +12335,A sample note on Rheumatoid Arthritis,34 +3124," Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.",3 +8515,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +8907,"Followup diabetes mellitus, type 1.",13 +5013,Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 +3834, Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,27 +8301,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 +9574,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +3940, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,15 +12096,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +6033,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +3204," Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.",14 +1320," A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. ",33 +6265,Patient presents to the emergency department (ED) with rectal bleeding and discomfort on defecation.,12 +5087,"Left neck dissection. Metastatic papillary cancer, left neck. The client had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.",16 +2622," Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. ",14 +3937, AP abdomen and ultrasound of kidney.,33 +4279,Occupational medicine consult with questions-answers and records review.,18 +3196, EGD with dilation for dysphagia.,38 +1705, CT Brain: Subarachnoid hemorrhage.,22 +9141,Autopsy of a white female who died of acute combined drug intoxication.,1 +9668,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +11202,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 +11065,Autopsy of a white female who died of acute combined drug intoxication.,1 +8202,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +10515,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 +10632,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +4546,"She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The case has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The case is starting to improve, gain more strength. She is tolerating her regular diet.",14 +10189,Sleep study - case with symptoms of obstructive sleep apnea with snoring.,36 +12291,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +12492,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +12132,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +4321,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",33 +883, Left little finger extensor tendon laceration. Repair of left little extensor tendon.,27 +10357,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +9501,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5752,"Phacoemulsification of cataract, extraocular lens implant in left eye.",26 +3029, Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings),24 +2577, 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. ,16 +8087,"The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.",13 +2553," Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.",27 +78, Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,38 +2602, An example/template for a routine normal male physical exam.,5 +12033,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +2691, Exploratory laparotomy and right salpingectomy.,38 +10375,"The case with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.",30 +7518,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +10559,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +102, Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. ,3 +7670,Work restrictions and disability evaluation,4 +205," Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",10 +7381,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7623,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +5418,Patient referred for narrow angles and possible associated glaucoma.,26 +1163," Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.",14 +11381,MRI report Cervical Spine (Chiropractic Specific),4 +11542,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +243, Brain CT and MRI - suprasellar mass (pituitary adenoma),33 +7463,Autopsy of a white female who died of acute combined drug intoxication.,1 +10545,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +514," Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",10 +11833,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +1622, Psychiatric consultation for substance abuse.,5 +4393,"Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.",16 +6486,The client continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,25 +2884," Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.",3 +11194,Occupational medicine consult with questions-answers and records review.,18 +12518,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11777,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +643, Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,33 +6343,Standard hypogastric plexus block procedure note.,28 +12598,Mother states he has been wheezing and coughing.,0 +12422,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +194," Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.",27 +1153, The patient was running and twisted her right ankle - right ankle sprain.,5 +7653,Patient presents for care of suspected rheumatoid arthritis.,34 +3602, An example/template for a routine normal female physical exam.,25 +1709, Reflex sympathetic dystrophy of both lower extremities.,22 +5690,"Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.",16 +1388," Right total knee arthroplasty - Osteoarthritis, right knee.",27 +1963, Patient today with multiple issues. ,15 +3038, A 2-month-old female with 1-week history of congestion and fever x2 days.,15 +10526,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +10340,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +4903,"Patient had a recurrent left arm discomfort after her stent, three days ago, and this persisted after two sublingual nitroglycerin.",12 +6104,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +4117,"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.",29 +3593, Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.,38 +7475,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +8452,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +5883,Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.,10 +4198,Diagnosis of benign rolandic epilepsy.,22 +7987,"A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.",8 +1279," Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.",38 +4217,"2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.",15 +7502,Autopsy - Asphyxia due to ligature strangulation.,1 +1705, CT Brain: Subarachnoid hemorrhage.,22 +9503,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +5777,Aftercare of multiple trauma from an motor vehicle accident.,10 +687, She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,15 +6481,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +3347," Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.",5 +7186,Evaluation and recommendations regarding facial rhytids.,8 +3858, Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,23 +10586,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +5541,Psychiatric consultation for substance abuse.,32 +11792,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +6084,Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.,16 +3665, Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.,11 +1325, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,14 +9991,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +874," Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain. ",33 +9455,"Specimen labeled ""sesamoid bone left foot"".",19 +7100,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4033,"Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.",23 +7482,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +2557, Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.,14 +5535,Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,23 +9423,Is it BNP or BMP?,19 +5579,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +8016,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 +5484,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +10833,Autopsy of a white female who died of acute combined drug intoxication.,1 +7652,Patient presents for care of suspected rheumatoid arthritis.,34 +9959,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +4048,"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.",10 +9898,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +2915, Newborn circumcision. The penile foreskin was removed using Gomco. ,29 +11876,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +4006,MRI Brain: Thrombus in torcula of venous sinuses.,33 +39," Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +11881,Patient presents for care of suspected rheumatoid arthritis.,34 +8367,"The client with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.",13 +1056, Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,38 +7613,A sample note on Rheumatoid Arthritis,34 +1154," DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,",38 +3098, A male referred to Wheelchair Clinic for evaluation for a new wheelchair. ,5 +7071,"Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.",29 +1394, Pediatric Gastroenterology - History of gagging.,29 +1515," Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.",10 +6210,4-day-old with hyperbilirubinemia and heart murmur.,29 +1635, Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.,3 +3971," Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",23 +12104,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +429, Upper endoscopy with removal of food impaction.,38 +1741," The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.",10 +3681, Quick note on tachypnea.,25 +8586,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +6736,Patient scheduled for laparoscopic gastric bypass.,2 +7178,Vaginal discharge with a foul odor.,12 +12082,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 +7148,"A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",32 +12259,A sample note on Rheumatoid Arthritis,34 +6363,Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.,11 +6369,Migraine headache - The client was seen in the urgent care.,12 +2672, Modified radical mastectomy. An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further. ,24 +10955,Patient presents for care of suspected rheumatoid arthritis.,34 +7133,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.",31 +781, Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +2844, Tonsillectomy. Chronic tonsillitis.,11 +12239,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9288,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +4123,"The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +1593, Repeat cesarean section and bilateral tubal ligation.,24 +10572,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +3043, Ultrasound - a 22-year-old pregnant female.,33 +11967,Evaluation for bariatric surgery.,2 +4271,Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.,15 +4767,Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,39 +2581," Patient with atrial fibrillation with slow ventricular response, partially due to medications.",3 +2510," Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.",39 +1092," Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. ",27 +8561,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +4031,"Complex regional discomfort syndrome, right upper extremity. Stellate ganglion block.",28 +5020,Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.,35 +8848,Dietary consultation for diabetes during pregnancy.,9 +10186,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10923,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +6297,Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.,26 +5120,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +1857, An example of a physical exam,5 +5462,Dietary consultation for diabetes during pregnancy.,9 +400," Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.",33 +322, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.,38 +10073,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.",36 +5750,"Phacoemulsification of cataract, extraocular lens implant in left eye.",26 +8605,"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.",30 +10367,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +979, Repair of upper lid canalicular laceration - Sample/Template.,38 +349," Bilateral rectus recession with the microscopic control, 8 mm, both eyes.",26 +7015,Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,26 +11636,Is it BNP or BMP?,19 +964, Common description of EGD.,14 +3607, Difficulty with both distance vision and with fine print at near.,5 +6789,"Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.",11 +3069, Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.,5 +8698,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +10741,"Specimen labeled ""sesamoid bone left foot"".",19 +4959,Lumbar epidural steroid injection for lumbar radiculopathy.,28 +9766,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +8319,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 +10721,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +12494,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +7497,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 +7049,Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The client is a 78-year-old female with back pain referring into the left side.,28 +4832,Consult and Spinal fluid evaluation in a 15-day-old,29 +182, Orchiopexy & inguinal herniorrhaphy.,38 +5301,"Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.",24 +982, Patient status post lap band placement.,38 +3630, 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.,5 +9500,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3709, Unilateral transpedicular T11 vertebroplasty.,38 +5413,This client was seen in clinic for a school physical.,29 +9932,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 +8500,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +10287,"Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.",13 +8391,Work restrictions and disability evaluation,4 +7002,"The case is 14 months old, comes in with a chief complaint of difficulty breathing.",12 +1128, Fractional dilatation and curettage,24 +8994,Autopsy - Homicide - Blunt force cranial trauma,1 +11467,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +9485,A sample note on Rheumatoid Arthritis,34 +5122,A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,32 +11784,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +3196, EGD with dilation for dysphagia.,38 +103, MRI report Cervical Spine (Chiropractic Specific),27 +12185,A 23-year-old white female presents with complaint of allergies.,0 +8000,Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.,8 +786," He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom.",35 +12113,Elevated cholesterol and is on medication to lower it.,9 +765, Sample/template for a normal female multisystem exam,5 +11697,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +2202, Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. ,2 +9376,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +2920," A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. ",39 +1639, The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.,5 +5089,"The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +12125,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +3313, Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.,38 +1411," Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2. +",38 +6046,Letter to the client to let him know about his abnormal cholesterol test results.,20 +8026,MRI report Cervical Spine (Chiropractic Specific),4 +757, Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,3 +2337," Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.",31 +7331,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +4004,This is a middle-aged female with two month history of low back ache and leg pain.,22 +3621, Laparoscopic cholecystectomy.,14 +11051,Autopsy - Homicide - Blunt force cranial trauma,1 +8142,Encephalopathy related to normal-pressure hydrocephalus.,30 +8287,The case was referred for evaluation of cataracts bilaterally,20 +818," Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.",38 +12425,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +9515,Autopsy of a white female who died of acute combined drug intoxication.,1 +3355, Pediatric Gastroenterology - Rectal Bleeding Consult.,14 +10111,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 +2757, Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.,39 +10342,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +3697," Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.",23 +6805,"Lumbar epidural steroid injection, L5-S1. Low back pain.",28 +241," Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. ",37 +1523, Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. ,38 +11740,Autopsy of a white female who died of acute combined drug intoxication.,1 +9416,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +3559," Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.",16 +11720,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +6014,"Fever, otitis media, and possible sepsis.",11 +7261,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +10187,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +10827,Autopsy of a white female who died of acute combined drug intoxication.,1 +9530,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +4287,Overactive bladder with microscopic hematuria.,39 +4836,"Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 +617, A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,5 +5133,The client is being referred for evaluation of diabetic retinopathy.,20 +2180," Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.",38 +1362, 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. ,38 +11572,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +590, Left third digit numbness and wrist pain.,27 +7970,Consultation for left foot pain.,4 +10566,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +7026,Sample/template for a normal male multisystem exam.,25 +4273,"Management of end-stage renal disease (ESRD), the case on chronic hemodialysis, being admitted for chest pain.",21 +2627," The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.",10 +9746,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +7992,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +12017,Consultation for left foot pain.,4 +6904,Sample post dilation client instructions.,26 +9277,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +2908," Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.",16 +338, Evaluation for chronic pain program,27 +1354," Sample normal ear, nose, mouth, and throat exam.",11 +7456,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +5552,"Sample normal ear, nose, mouth, and throat exam.",11 +335, MRI Brain & T-spine - Demyelinating disease.,33 +6367,"Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.",37 +6416,Consult for laparoscopic gastric bypass.,2 +12443,A sample note on Rheumatoid Arthritis,34 +10317,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 +8204,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 +8622,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +1735," A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.",5 +11041,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +9971,"Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain.",30 +5576,Endoscopic proximal shunt revision.,23 +11468,Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.,18 +9415,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 +12368,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +9652,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +4169,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 +5111,"School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 +9823,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +5990,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,28 +8099,Occupational medicine consult with questions-answers and records review.,18 +9625,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +606," Phacoemulsification of cataract and posterior chamber lens implant, right eye.",26 +781, Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 +5080,"Repair of left inguinal hernia indirect. The case states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the case was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.",39 +2181, Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,38 +8029,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 +10830,Autopsy of a white female who died of acute combined drug intoxication.,1 +6183,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +9649,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7766,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +5101,A 23-year-old white female presents with complaint of allergies.,0 +5049,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.,24 +569," Creation of AV fistula, left wrist in the anatomic snuffbox.",21 +11454,Consultation for wrist pain.,4 +7743,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +10981,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +8281,"Female with intermittent rectal bleeding, not associated with any weight loss. The case is chronically constipated.",20 +4789,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +3506," Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.",15 +1402," CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.",22 +9695,A sample note on Rheumatoid Arthritis,34 +11166,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +2399," Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.",15 +49, MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 +9945,Occupational medicine consult with questions-answers and records review.,18 +11125,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +253," History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.",5 +4540,Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,23 +2660," Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",22 +7470,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +9999,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +4820,"Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +9541,Cause of death - Anoxic Encephalopathy,1 +9836,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +4195,Procedure note on Keller Bunionectomy,31 +9524,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +10809,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +294," Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.",24 +6996,"A 44-year-old, 250-pound male presents with extreme ache in his left heel.",31 +8577,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.,37 +2101," Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.",27 +8898,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 +1284, Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,38 +4426,CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,11 +6795,"Synovitis - anterior cruciate ligament tear of the left knee. The case is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The case fell in a grocery store. He reports slipping on a grape that was on the floor.",30 +2, This is a middle-aged female with two month history of low back pain and leg pain.,22 +7139,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +2052," A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.",35 +4897,"Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.",21 +3773, CT of Brain - Subacute SDH.,33 +8136,Consult for laparoscopic gastric bypass.,2 +8160,Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.,7 +6697,"Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.",11 +6510,"Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.",36 +1919, Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,38 +4893,A sample note on bilateral myringotomy tubes,11 +1845," Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. ",5 +10621,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +8230,Qualified healthcare evaluation report of a patient with back pain.,18 +11709,Autopsy - Homicide - Blunt force cranial trauma,1 +4154,Normal upper GI endoscopy.,14 +5070,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +3486, Right nodular malignant mesothelioma.,16 +5763,Consultation for evaluation of thrombocytopenia.,16 +9392,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +7369,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +12137,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +8558,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..",7 +3611," Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.",27 +5497,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5741,CT scan of the abdomen and pelvis without and with intravenous contrast.,21 +2447, MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,33 +11609,A 23-year-old white female presents with complaint of allergies.,0 +3737, Common CT C-Spine template,33 +2871," The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.",35 +11843,A sample note on Rheumatoid Arthritis,34 +2168, An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,38 +342, Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.,27 +3073," Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.",38 +10873,Cause of death - Anoxic Encephalopathy,1 +7609,A sample note on Rheumatoid Arthritis,34 +8395,Work restrictions and disability evaluation,4 +11579,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 +4419,A 61-year-old white male with a identification of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,35 +4820,"Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.",22 +104, Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. ,11 +7308,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 +3184, A 16-year-old male with Q-fever endocarditis.,35 +1040," Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. ",39 +7949,"Specimen labeled ""sesamoid bone left foot"".",19 +5211,"EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.",36 +11587,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 +1076," Hypomastia. Patient wants breast augmentation and liposuction of her abdomen, ",5 +1472," Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.",3 +9202,Consultation for wrist pain.,4 +8013,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 +665, Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,35 +8005,The case underwent an overnight polysomnogram.,36 +9144,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5063,"This is a 53-year-old man, who presented to emergency room with multiple complaints including discomfort from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.",12 +6925,"Lower quadrant discomfort with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.",21 +5687,"Left orchiectomy, scrotal exploration, right orchidopexy.",39 +3714," The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.",5 +11063,Autopsy of a white female who died of acute combined drug intoxication.,1 +7843,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 +6563,Patient in ER complaining of shortness of breath (COPD),12 +147," Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.",3 +9119,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 +5365,Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,24 +4629,"Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",29 +7150,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +692," Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.",27 +570, Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. ,22 +9772,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +2925," Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.",15 +8138,Patient today with ongoing issues with diabetic control.,13 +8791,Is it BNP or BMP?,19 +11817,Patient presents for care of suspected rheumatoid arthritis.,34 +8111,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +5432,Emergency cesarean section.,24 +1141, Cardiology office visit sample note.,3 +9996,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +2723," Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.",3 +311, Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 +12532,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 +12622,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +10532,Occupational medicine consult with questions-answers and records review.,18 +4861,"Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.",10 +225, H&P for a female with Angina pectoris.,3 +6187,"Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.",16 +4138,"The client is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",12 +10286,Occupational medicine consult with questions-answers and records review.,18 +8796,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 +4847,Excision of penile skin bridges about 2 cm in size.,39 +11053,A sample note on Rheumatoid Arthritis,34 +4257,"The case is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.",24 +9137,Autopsy of a white female who died of acute combined drug intoxication.,1 +12623,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +6728,L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,28 +6648,Newborn circumcision. The penile foreskin was removed using Gomco.,29 +1874, Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. ,39 +4811,Injection of Morton's neuroma.,28 +3794, Autopsy - Asphyxia due to ligature strangulation.,1 +1569, This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,36 +11321,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +4100,Bilateral temporal artery biopsy. Rule out temporal arteritis.,22 +3343," Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.",38 +8830,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 +2326, Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,38 +8945,Consultation for left foot pain.,4 +3789," Total abdominal hysterectomy.. Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.",38 +5844,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +4121,Closure of gastrostomy placed due to feeding difficulties.,14 +5694,2-month-old female - increased work of breathing.,12 +8981,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +4673,"Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 +8619,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 +11657,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 +11106,Patient presents for therapy of suspected rheumatoid arthritis.,34 +4026,"Laparoscopic tubal sterilization, tubal coagulation.",24 +9070,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 +8853,"History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.",30 +8872,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +8891,The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.,37 +9920,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +8393,Work restrictions and disability evaluation,4 +2174, Bronchoscopy. Atelectasis and mucous plugging.,3 +5163,"Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.",8 +4017,"Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.",7 +5363,"Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.",24 +530, Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,28 +1143," Follow up consultation, second opinion, foreskin.",35 +11433,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 +4809,MRI C-spine: C4-5 Transverse Myelitis.,22 +9746,"Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.",34 +9080,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +633," Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",38 +1418, Patient with worsening shortness of breath and cough.,15 +4205,Left forearm arteriovenous fistula between cephalic vein and radial artery.,21 +5198,"Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.",26 +472, AP abdomen and ultrasound of kidney.,21 +6463,Nephrology Consultation - Patient with renal failure.,21 +2028," Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.",38 +356," Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.",22 +3101," Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.",38 +9771,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +5109,"School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.",32 +6598,Discharge summary of a case with mood swings and oppositional and defiant behavior.,32 +3729, Patient being referred for evaluation of glaucoma.,20 +9300,Autopsy - Asphyxia due to ligature strangulation.,1 +7117,The case presents for evaluation at the request of his primary physician for treatment for dystrophic nails.,31 +2575, Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.,38 +3913, Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.,27 +3829," CT abdomen without contrast and pelvis without contrast, reconstruction.",33 +8669,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 +2357, Sample for Neuropsychological Evaluation,22 +8466,Occupational medicine consult with questions-answers and records review.,18 +7111,Autopsy - Asphyxia due to ligature strangulation.,1 +2513," Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.",6 +9268,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +12053,Preop evaluation regarding gastric bypass surgery.,2 +6016,"Fever, otitis media, and possible sepsis.",11 +7349,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 +6817,Coccygeal injection,28 +4462,"Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to clinical therapy, severe anemia, and symptomatic fibroid uterus.",10 +2070, A sample note on Angina.,3 +6072,The patient's main complaint is vertigo. The client is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.,11 +4613,"This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.",10 +9315,"The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.",37 +6142,"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.",21 +8129,Punch biopsy of right upper chest skin lesion.,8 +2307, The patient is status post C3-C4 anterior cervical discectomy and fusion.,30 +11731,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +577, Injection of Morton's neuroma.,28 +12209,Is it BNP or BMP?,19 +3132, History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.,15 +12494,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 +5463,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,24 +3299, A male patient presented for evaluation of chronic abdominal pain.,15 +10917,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 +8346,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 +2273," A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. ",10 +3235, MRI right knee without gadolinium,33 +8315,Patient being referred for evaluation of glaucoma.,20 +4986,Consultation for ICU management for a client with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 +11479,Qualified medical evaluation report of a case with back pain.,18 +4790,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 +12072,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +2643," Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 +9699,A sample note on Rheumatoid Arthritis,34 +4642,"A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",29 +9185,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.,17 +5943,"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.",23 +10378,Patient scheduled for laparoscopic gastric bypass.,2 +9922,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 +3232," Right knee total arthroplasty. Degenerative osteoarthritis, right knee.",27 +721," Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication. ",38 +7347,Work restrictions and disability evaluation,4 +5759,The client with continued problems with her headaches.,25 +10642,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 +962," Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.",39 +9947,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 +11395,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 +732," Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.",5 +171, Overactive bladder with microscopic hematuria.,39 +740, Acute appendicitis and 29-week pregnancy. Appendectomy.,38 +5869,Template for History and Physical for a newborn.,25 +4870,"Right inguinal hernia. Right inguinal hernia repair. The case is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 +9888,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +870," Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.",11 +10724,"Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.",19 +5793,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 +5342,Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.,23 +7837,"The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 +10760,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 +30, Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. ,10 +8086,Consult for laparoscopic gastric bypass.,2 +11932,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +7757,"Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth discomfort to both upper and lower teeth on the left side for approximately three days..",7 +9773,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +1527, Patient today with ongoing issues with diabetic control.,35 +7506,"The client was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The client attended nine outpatient skilled speech therapy sessions.",37 +11879,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +9902,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 +5047,Cardiology office visit sample note.,25 +578, Itchy red rash on feet - Tinea Pedis,5 +9506,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 +8396,Work restrictions and disability evaluation,4 +2446, Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.,5 +8594,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 +936, Work restrictions and disability evaluation ,18 +2511, Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.,38 +1449," Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.",38 +11760,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 +11676,"Specimen labeled ""sesamoid bone left foot"".",19 +3195, The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,5 +4744,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 +5330,Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 +2842," Specimen labeled ""sesamoid bone left foot"".",27 +2124," Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.",38 +9981,"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.",20 +3521, Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,22 +8518,Chiropractic IME with answers to questions from Insurance Company.,20 +4409,"Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.",23 +9751,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +7815,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 +7782,"Negative for any nausea, vomiting, fevers, chills, or weight loss.",25 +4124,"The client was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.",25 +5689,"Left orchiectomy, scrotal exploration, right orchidopexy.",39 +9322,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 +11299,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 +7994,Sleep study - client with symptoms of obstructive sleep apnea with snoring.,36 +6409,13 years old complaining about severe ear discomfort - Chronic otitis media.,29 +12031,A sample note on Rheumatoid Arthritis,34 +10436,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 +6217,"The client is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.",16 +10226,"Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation",20 +6376,Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,26 +374," A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.",5 +9692,A sample note on Rheumatoid Arthritis,34 +1756," Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication. ",3 +10411,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 +1249, The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.,38 +1517, The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,3 +4404,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +8713,A 23-year-old white female presents with complaint of allergies.,0 +11921,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 +6516,Complete eye examination - Normal eye and vision exam.,26 +8225,"He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.",20 +4200,"Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.",24 +2188, Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,27 +5328,Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 +6780,Blepharoplasty with direct brow repair.,26 +6585,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 +3207," The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. ",5 +5764,Consultation for evaluation of thrombocytopenia.,16 +7617,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 +3471, Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,38 +7455,"Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.",19 +3062," Hardware removal, right ulnar",38 +7353,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 +3728, Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,38 +1806, Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.,38 +12, Work restrictions and disability evaluation ,4 +2960, The patient is in complaining of headaches and dizzy spells.,15