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int64
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12.7k
description
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492
medical_specialty
int64
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39
10,400
Chronic snoring in children
36
7,754
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
4,912
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
1,011
Psychosocial Evaluation of patient before kidney transplant.
21
1,199
Chiropractic IME with old files review. Detailed Thoracic Spine Examination.
18
3,814
Cystopyelogram and laser vaporization of the prostate.
38
11,739
Autopsy of a white female who died of acute combined drug intoxication.
1
6,738
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
4,230
Sample progress note - Gen Med.
15
1,993
Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.
38
3,315
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
6,241
Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.
11
5,883
Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.
10
8,020
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
12,436
A female for a complete physical and follow up on asthma with allergic rhinitis.
0
10,932
Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.
17
4,168
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
4,577
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
12,438
Autopsy - Homicide - Blunt force cranial trauma
1
2,595
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
2,777
Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.
27
2,453
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
5,842
Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.
23
8,666
Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
6
12,157
Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.
37
4,432
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
4,242
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
3,997
Repair of bilateral cleft of the palate with vomer flaps.
11
7,230
Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.
1
11,540
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
10,444
A lady with symptoms consistent with possible oligoarticular arthritis of her knees.
34
8,071
Specimen labeled "right ovarian cyst" is received fresh for frozen section.
19
4,188
Patient with intermittent episodes of severe nausea and abdominal pain.
15
9,136
Autopsy of a white female who died of acute combined drug intoxication.
1
11,771
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
3,891
Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.
38
3,481
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
1,083
General Medicine SOAP note.
35
6,375
Phacoemulsification with posterior chamber intraocular lens implant in the right eye.
26
1,951
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
1,964
Neurologic examination sample.
35
7,848
Work restrictions and disability evaluation
18
5,550
Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
31
1,444
Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.
38
7,225
Is it BNP or BMP?
19
11,813
A lady with symptoms consistent with possible oligoarticular arthritis of her knees.
34
2,601
Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.
27
7,221
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
5,496
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
3,723
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
1,289
Woman with adult hydrocephalus, routine evaluation.
22
11,662
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
4,070
Normal Circumcision
39
3,119
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
5,597
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
2,741
Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.
35
3,064
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
2,625
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
3,360
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
9,419
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
6,183
Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.
2
11,233
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
10,216
Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.
4
1,000
Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.
24
6,495
CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.
21
9,078
Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.
37
12,080
Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.
9
4,972
Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.
35
10,248
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
11,418
Autopsy of a white female who died of acute combined drug intoxication.
1
2,565
Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.
11
1,816
Pain and swelling in the right foot.
31
7,491
Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.
0
7,672
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
8,555
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
4,417
A 2-month-old female with 1-week history of congestion and fever x2 days.
29
8,884
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
4,780
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
9,412
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
12,228
Specimen labeled "sesamoid bone left foot".
19
9,738
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
5,140
Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision. Recurrent right inguinal hernia, as well as phimosis.
39
11,006
A 23-year-old white female presents with complaint of allergies.
0
5,082
Right radical nephrectomy and assisted laparoscopic approach.
21
2,822
A middle-aged female with memory loss.
33
4,264
A 65-year-old man with chronic prostatitis returns for recheck.
35
7,389
Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.
2
5,868
Template for History and Physical for a newborn.
25
5,691
Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.
16
2,707
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
1,737
Headache and diplopia.
22