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9,852 | 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 |
2,184 | Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated. | 28 |
7,833 | Normal awake and drowsy (stage I sleep) EEG for patient's age. | 36 |
5,311 | Bilateral myringotomies with insertion of Santa Barbara T-tube. | 11 |
10,488 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
5,640 | 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 |
7,090 | Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. | 2 |
7,997 | Autopsy - Homicide - Blunt force cranial trauma | 1 |
8,339 | Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. | 37 |
10,624 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | 17 |
8,833 | 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 |
7,523 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
11,656 | Autopsy - Homicide - evidence of exsanguination - multiple stab wounds. | 1 |
9,123 | Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. | 2 |
4,884 | Incision and drainage, first metatarsal head, left foot with culture and sensitivity. | 10 |
10,282 | The client is status post C3-C4 anterior cervical discectomy and fusion. | 30 |
4,846 | Excision of penile skin bridges about 2 cm in size. | 39 |
6,071 | 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 |
2,054 | 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 |
7,179 | Vaginal discharge with a foul odor. | 12 |
5,487 | 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 |
9,348 | Patient presents for therapy of suspected rheumatoid arthritis. | 34 |
7,445 | A sample note on Rheumatoid Arthritis | 34 |
7,237 | Mother states he has been wheezing and coughing. | 0 |
1,369 | Progressive loss of color vision OD. | 22 |
11,494 | 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 |
2,632 | 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 |
8,965 | Mother states he has been wheezing and coughing. | 0 |
6,794 | 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 |
6,470 | Psychiatric evaluation for ADHD, combined type. | 32 |
3,488 | Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32. | 38 |
11,313 | Dietary consultation for diabetes during pregnancy. | 9 |
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 |
6,673 | Sample/template for a normal female multisystem exam | 25 |
580 | Patient in with mom for possible ear infection. | 15 |
3,081 | Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP). | 38 |
3,257 | Blepharoplasty with direct brow repair. | 38 |
6,500 | CT abdomen and pelvis without contrast, stone protocol, reconstruction. | 21 |
2,125 | 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 |
9,179 | 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 |
2,255 | 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 |
11,661 | 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 |
2,542 | 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 |
10,665 | Evaluation for bariatric surgery. | 2 |
2,829 | 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 |
2,657 | 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 |
9,699 | A sample note on Rheumatoid Arthritis | 34 |
9,938 | Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy. | 7 |
9,519 | Autopsy of a white female who died of acute combined drug intoxication. | 1 |
8,043 | 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 |
8,079 | 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 |
3,462 | T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation. | 5 |
8,230 | Qualified healthcare evaluation report of a patient with back pain. | 18 |
10,453 | 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 |
3,634 | Right radical nephrectomy and assisted laparoscopic approach. | 38 |
5,206 | Cystoscopy, bladder biopsies, and fulguration. Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending. | 39 |
4,054 | Bilateral Myringotomy with placement of PE tubes | 11 |
10,271 | Consult for laparoscopic gastric bypass. | 2 |
8,824 | Chiropractic IME with old files review. Detailed Thoracic Spine Examination. | 18 |
1,783 | Severe tonsillitis, palatal cellulitis, and inability to swallow. | 11 |
1,817 | 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 |
6,951 | Onychomycosis present, #1, #2, #3, #4, and #5 right and left. | 31 |
3,534 | Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. | 5 |
6,182 | Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. | 2 |
6,689 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | 9 |
10,195 | The case underwent an overnight polysomnogram. | 36 |
3,994 | 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 |
10,814 | 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 |
6,321 | Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis. | 11 |
10,031 | The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. | 36 |
9,698 | A sample note on Rheumatoid Arthritis | 34 |
5,766 | Evaluation for right L4 selective nerve root block. | 28 |
6,307 | 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 |
8,420 | Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes. | 13 |
6,829 | 13 years old complaining about severe ear ache - Chronic otitis media. | 11 |
10,761 | A female for a complete physical and follow up on asthma with allergic rhinitis. | 0 |
4,532 | Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. | 35 |
11,508 | Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs. | 17 |
10,886 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | 9 |
10,372 | 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 |
9,630 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
6,229 | 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 |
5,197 | Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye. | 26 |
2,015 | Irritable baby, 6-week-old, with fever for approximately 24 hours. | 5 |
8,606 | 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 |
5,094 | Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis. | 16 |
5,059 | Burr hole and insertion of external ventricular drain catheter. | 23 |
2,030 | 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 |
1,510 | Cystoscopy, cryosurgical ablation of the prostate. | 38 |
1,860 | 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 |
11,256 | The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. | 36 |
12,496 | Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs. | 17 |
6,334 | Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty. | 11 |