Datasets:

bhargavi909

/

Medical_Transcriptions_upsampled

like 2

The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.

Chiropractic IME with answers to questions from Insurance Company.

A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

Psychiatric Assessment of a case with bipolar and anxiety disorder having posttraumatic stress syndrome.

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.

Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.

Nausea, vomiting, diarrhea, and fever.

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.

A sample note on Rheumatoid Arthritis

The patient had undergone mitral valve repair about seven days ago.

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.

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.

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.

A 5-month-old boy brought by his parents because of 2 days of cough.

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

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.

Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.

Acute foot or ankle sprain, possible small fracture.

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.

Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.

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.

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.

Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

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.

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.

Pain and swelling in the right foot, peroneal tendon tear.

Chiropractic IME with answers to questions from Insurance Company.

Bronchoscopy. Atelectasis and mucous plugging.

Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

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.

Transforaminal epidural steroid block with fluoroscopy.

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.

Mother states he has been wheezing and coughing.

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.

Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.

A 23-year-old white female presents with complaint of allergies.

Patient presents for care of suspected rheumatoid arthritis.

CT Brain: Midbrain hemangioma

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.

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.

Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.

Patient presents for care of suspected rheumatoid arthritis.

Work restrictions and disability evaluation

Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.

Acromioclavicular joint injection

Psychological Testing for ADHD

Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.

Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.

Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.

Autopsy of a white female who died of acute combined drug intoxication.

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.

Dietary consultation for gestational diabetes.

Single frontal view of the chest. Respiratory distress. The client has a history of malrotation.

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.

A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

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.

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.

A sample note on Rheumatoid Arthritis

Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.

Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

A 65-year-old man with chronic prostatitis returns for recheck.

Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.

Request for consultation to evaluate stomatitis, possibly methotrexate related.

Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.

Psychosocial Evaluation of client before kidney transplant.

Dietary consultation for diabetes during pregnancy.

The client noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.

Evaluation for bariatric surgery.

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.

Consult for laparoscopic gastric bypass.

Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.

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.

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.

Patient discharged after laparoscopic Roux-en-Y gastric bypass.

The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.

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.

Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.

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.

A 23-year-old white female presents with complaint of allergies.

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.

Chiropractic IME with answers to questions from Insurance Company.

Repair of ruptured globe with repositing of uveal tissue - Sample/Template.

Work restrictions and disability evaluation

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.

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

Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.

He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.

Pain and swelling in the right foot.

Is it BNP or BMP?

Is it BNP or BMP?

This case has reoccurring ingrown infected toenails.

Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.

Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

Status post cadaveric kidney transplant with stable function.

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.