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Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:, None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day.,SOCIAL HISTORY: ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings.,HEART: Regular rate and rhythm, without murmur. Normal S1, S2.,LUNGS: Clear. No rales. No wheeze. Good excursion.,ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES: No edema, clubbing, or cyanosis. No rash.,LABORATORY FINDINGS: , On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1. Hypoglycemia due to not eating her meals on a regular basis.,2. Hypertension.,3. Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.

Patient was found to have decrease in mental alertness

Consult - History and Phy.

Gen Med Consult - 30

the, no, her, also, patient

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:, None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day.,SOCIAL HISTORY: ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings.,HEART: Regular rate and rhythm, without murmur. Normal S1, S2.,LUNGS: Clear. No rales. No wheeze. Good excursion.,ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES: No edema, clubbing, or cyanosis. No rash.,LABORATORY FINDINGS: , On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1. Hypoglycemia due to not eating her meals on a regular basis.,2. Hypertension.,3. Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Patient was found to have decrease in mental alertness [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS: ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:, Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:, Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout.

Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.

Surgery

Total Thyroidectomy

surgery, thyroid goiter, goiter, thyroid, total thyroidectomy, berry's ligament, dissection, gland, thyroidectomy, anesthesia, berry's, ligament, cauterization, extension, substernal,

the, and, then, was, with

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:, Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:, Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left. [/DESCRIPTION] </s>

Extract key medical terms from this text

chest, the, and, of, mg

PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.

Chest tube talc pleurodesis of the right chest.

Surgery

Pleurodesis

surgery, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube

chest, the, and, of, mg

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning. [/TRANSCRIPTION] [TASK_OUTPUT] chest, the, and, of, mg [/TASK_OUTPUT] [DESCRIPTION] Chest tube talc pleurodesis of the right chest. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Colonoscopy With Photos

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Diverticulosis coli.,2. Internal hemorrhoids.,3. Poor prep.,PROCEDURE PERFORMED:, Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:, None.,HISTORY:, 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.,PROCEDURE:, After proper informed consent was obtained, the patient was brought to the Endoscopy Suite. She was placed in the left lateral position and was given sedation by the Anesthesia Department. A digital rectal exam was performed and there was no evidence of mass. The colonoscope was then inserted into the rectum. There was some solid stool encountered. The scope was maneuvered around this. There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon. The scope was then passed through the transverse colon and ascending colon to the cecum. No masses or polyps were noted. Visualization of the portions of the colon was however somewhat limited. There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls. Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted. The scope was then completely withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.

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.

Gastroenterology

Colonoscopy With Photos

gastroenterology, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope

the, was, and, performed, to

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Diverticulosis coli.,2. Internal hemorrhoids.,3. Poor prep.,PROCEDURE PERFORMED:, Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:, None.,HISTORY:, 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.,PROCEDURE:, After proper informed consent was obtained, the patient was brought to the Endoscopy Suite. She was placed in the left lateral position and was given sedation by the Anesthesia Department. A digital rectal exam was performed and there was no evidence of mass. The colonoscope was then inserted into the rectum. There was some solid stool encountered. The scope was maneuvered around this. There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon. The scope was then passed through the transverse colon and ascending colon to the cecum. No masses or polyps were noted. Visualization of the portions of the colon was however somewhat limited. There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls. Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted. The scope was then completely withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin. [/TRANSCRIPTION] [TASK_OUTPUT] Colonoscopy With Photos [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Summarize this medical transcription

Patient in ER due to colostomy failure - bowel obstruction.

CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, "Fleet enema." ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.

Patient in ER due to colostomy failure - bowel obstruction.

Gastroenterology

Colostomy Failure

the, or, of, patient, is

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, "Fleet enema." ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable. [/TRANSCRIPTION] [TASK_OUTPUT] Patient in ER due to colostomy failure - bowel obstruction. [/TASK_OUTPUT] [DESCRIPTION] Patient in ER due to colostomy failure - bowel obstruction. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation

Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.

SOAP / Chart / Progress Notes

Multiple Progress Notes

blood, in, from, and, lower

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Peritoneal Dialysis Catheter Insertion

PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.

A 14-year-old young lady is in the renal failure and in need of dialysis.

Surgery

Peritoneal Dialysis Catheter Insertion

surgery, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal

the, and, was, through, incision

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] Peritoneal Dialysis Catheter Insertion [/TASK_OUTPUT] [DESCRIPTION] A 14-year-old young lady is in the renal failure and in need of dialysis. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks.

Sample cardiology office visit note.

Cardiovascular / Pulmonary

Cardiology Office Visit - 1

mg, is, patient, to, in

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Sample cardiology office visit note. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.

Orthopedic

Bilateral Hip Pain

orthopedic, bilateral hip pain, femoroacetabular, impingement, hip,

the, she, is, and, as

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Consult - History and Phy.

REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above.

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.

Consult - History and Phy.

Dilated Cardiomyopathy - Consult

he, his, is, and, the

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above. [/TRANSCRIPTION] [TASK_OUTPUT] Consult - History and Phy. [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,

1. Odynophagia.,2. Dysphagia.,3. Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Hiatal hernia.,PROCEDURE PERFORMED: EGD with photos and biopsies.,GROSS FINDINGS: 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. At this time, an EGD was performed to rule out stricture. At the time of EGD, there was noted some antral gastritis and hiatal hernia. There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE: The patient was taken to the Endoscopy Suite in the lateral decubitus position. She was given sedation by the Department Of Anesthesia. Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx. With air insufflation entered through the proximal esophagus to the GE junction. The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices. There was a hiatal hernia present. The scope was passed through the hiatal hernia into the body of the stomach. In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions. Multiple biopsies were obtained. The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits. The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction. As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn. The patient tolerated the procedure well and sent to recovery room in satisfactory condition.

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.

Surgery

EGD With Photos & Biopsies.

surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,

the, was, through, into, and

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] 1. Odynophagia.,2. Dysphagia.,3. Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Hiatal hernia.,PROCEDURE PERFORMED: EGD with photos and biopsies.,GROSS FINDINGS: 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. At this time, an EGD was performed to rule out stricture. At the time of EGD, there was noted some antral gastritis and hiatal hernia. There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE: The patient was taken to the Endoscopy Suite in the lateral decubitus position. She was given sedation by the Department Of Anesthesia. Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx. With air insufflation entered through the proximal esophagus to the GE junction. The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices. There was a hiatal hernia present. The scope was passed through the hiatal hernia into the body of the stomach. In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions. Multiple biopsies were obtained. The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits. The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction. As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn. The patient tolerated the procedure well and sent to recovery room in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia, [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.68

REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, 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. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1. Vitamin supplementation.,2. Prednisone.,3. Cyclobenzaprine.,4. Losartan 50 mg daily.,5. Nifedipine 90 mg daily.,6. Lasix.,7. Potassium supplementation.,ALLERGIES:, SULFA.,PERSONAL HISTORY:, He is an ex-smoker. Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally clear, rales are scattered.,HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.,ABDOMEN: Soft, nontender.,EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.,IMPRESSION:,1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2. Septicemia, septic shock secondary to cellulitis of the leg.,3. Acute renal shutdown.,4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2. Aggressive medical management including dialysis.,3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4. Explained to patient's family in detail regarding condition which is critical which they are aware of.

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.

Consult - History and Phy.

Elevated Cardiac Enzymes

history, of, the, he, is

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, 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. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1. Vitamin supplementation.,2. Prednisone.,3. Cyclobenzaprine.,4. Losartan 50 mg daily.,5. Nifedipine 90 mg daily.,6. Lasix.,7. Potassium supplementation.,ALLERGIES:, SULFA.,PERSONAL HISTORY:, He is an ex-smoker. Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally clear, rales are scattered.,HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.,ABDOMEN: Soft, nontender.,EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.,IMPRESSION:,1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2. Septicemia, septic shock secondary to cellulitis of the leg.,3. Acute renal shutdown.,4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2. Aggressive medical management including dialysis.,3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4. Explained to patient's family in detail regarding condition which is critical which they are aware of. [/TRANSCRIPTION] [TASK_OUTPUT] 0.68 [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Gastroenterology - Letter

Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:, Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:, The patient denies any past surgical history.,MEDICATIONS:, The patient takes Cardizem CD 240-mg. The patient also takes eye drops.,ALLERGIES:, The patient denies any allergies.,SOCIAL HISTORY:, The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially.,FAMILY HISTORY:, Significant for hypertension and strokes.,REVIEW OF SYSTEMS:, The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:, This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema.,IMPRESSION:, This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.,1. Rule out colon cancer.,2. Rule out colon polyps. ,3. Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:, Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD

Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated.

Letters

Gastroenterology - Letter

any, the, patient, no, is

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:, Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:, The patient denies any past surgical history.,MEDICATIONS:, The patient takes Cardizem CD 240-mg. The patient also takes eye drops.,ALLERGIES:, The patient denies any allergies.,SOCIAL HISTORY:, The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially.,FAMILY HISTORY:, Significant for hypertension and strokes.,REVIEW OF SYSTEMS:, The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:, This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema.,IMPRESSION:, This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.,1. Rule out colon cancer.,2. Rule out colon polyps. ,3. Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:, Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD [/TRANSCRIPTION] [TASK_OUTPUT] Gastroenterology - Letter [/TASK_OUTPUT] [DESCRIPTION] Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, was, and, to, of

PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.

Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

Surgery

Lumbar Laminotomy & Discectomy

surgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,

the, was, and, to, of

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications. [/TRANSCRIPTION] [TASK_OUTPUT] the, was, and, to, of [/TASK_OUTPUT] [DESCRIPTION] Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Speech - Language

CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS: ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1. Completion of modified barium swallow study.,2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. The patient will increase laryngeal elevation by 50% for airway protection.,4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1. The patient will improve secretion management to tolerable levels.,2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.

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.

Speech - Language

Barium Swallow Study & Speech Evaluation

the, patient, to, of, and

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS: ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1. Completion of modified barium swallow study.,2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. The patient will increase laryngeal elevation by 50% for airway protection.,4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1. The patient will improve secretion management to tolerable levels.,2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve. [/TRANSCRIPTION] [TASK_OUTPUT] Speech - Language [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Angiography & Catheterization - 1

INDICATION:, Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:, 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.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.,2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.,2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.,3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months.

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.

Surgery

Angiography & Catheterization - 1

surgery, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal,

the, artery, left, was, using

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] INDICATION:, Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:, 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.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.,2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.,2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.,3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months. [/TRANSCRIPTION] [TASK_OUTPUT] Angiography & Catheterization - 1 [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.

Repair of bilateral cleft of the palate with vomer flaps.

Surgery

Cleft Repair

surgery, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,

the, of, was, and, with

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Repair of bilateral cleft of the palate with vomer flaps. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.44

PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them. The large and small bowels were completely enveloping a large right ovarian cystic mass. Normal anatomy was difficult to see due to adhesions. Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid. Cyst wall, tube, and ovary were stripped away from the bowel. Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube. There was excellent postoperative hemostasis.,PROCEDURE: ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty. She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion. A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision. Incision was carried down carefully until the peritoneal cavity was reached. Care was taken upon entry of the peritoneum to avoid injury of underlying structures. At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery. The omentum was carefully stripped away from the patient's right side developing a window. This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum. A large mass of bowel was noted to be adherent to itself causing a quite tortuous course. Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis. Excellent hemostasis was noted. The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst. Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst. Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured. Large amount of turbid fluid was noted and was evacuated. The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel. Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter. This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl. A suture ligature of #0 Vicryl was used to obtain hemostasis. Excellent hemostasis was noted at this pedicle. The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum. Care was taken at the side of the remnant of the uterine vessels. However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted. Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube. Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal. It was then left in situ. Hemostasis was achieved in the pelvis with the use of electrocautery. The abdomen and pelvis were copiously irrigated with warm saline solution. The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle. The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen. The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly. Excellent closure of the incision was noted. The subcutaneous tissues were then copiously irrigated. Hemostasis was achieved with the use of cautery. Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture. The skin was closed with staples.,Incision was sterilely clean and dressed. The patient was awakened from general anesthesia and taken to the recovery room in stable condition. All counts were noted correct times three.

Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst.

Surgery

Exploratory Laparotomy - 2

surgery, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis,

the, was, and, of, to

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them. The large and small bowels were completely enveloping a large right ovarian cystic mass. Normal anatomy was difficult to see due to adhesions. Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid. Cyst wall, tube, and ovary were stripped away from the bowel. Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube. There was excellent postoperative hemostasis.,PROCEDURE: ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty. She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion. A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision. Incision was carried down carefully until the peritoneal cavity was reached. Care was taken upon entry of the peritoneum to avoid injury of underlying structures. At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery. The omentum was carefully stripped away from the patient's right side developing a window. This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum. A large mass of bowel was noted to be adherent to itself causing a quite tortuous course. Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis. Excellent hemostasis was noted. The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst. Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst. Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured. Large amount of turbid fluid was noted and was evacuated. The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel. Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter. This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl. A suture ligature of #0 Vicryl was used to obtain hemostasis. Excellent hemostasis was noted at this pedicle. The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum. Care was taken at the side of the remnant of the uterine vessels. However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted. Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube. Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal. It was then left in situ. Hemostasis was achieved in the pelvis with the use of electrocautery. The abdomen and pelvis were copiously irrigated with warm saline solution. The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle. The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen. The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly. Excellent closure of the incision was noted. The subcutaneous tissues were then copiously irrigated. Hemostasis was achieved with the use of cautery. Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture. The skin was closed with staples.,Incision was sterilely clean and dressed. The patient was awakened from general anesthesia and taken to the recovery room in stable condition. All counts were noted correct times three. [/TRANSCRIPTION] [TASK_OUTPUT] 0.44 [/TASK_OUTPUT] [DESCRIPTION] Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst. [/DESCRIPTION] </s>

Extract original key medical terms from this text

dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,

PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition.

Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.

Dentistry

Extraoral I&D

dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,

the, was, and, of, left

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:, Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS: ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:, Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:, One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE: ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally __________ suction. The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point, the procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transported to PACU in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth, [/TASK_OUTPUT] [DESCRIPTION] Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

ADMITTING DIAGNOSIS:, A nonhealing right below-knee amputation.,DISCHARGE DIAGNOSIS:, A nonhealing right below-knee amputation.,SECONDARY DIAGNOSES:, Include:,1. Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies.,2. Peripheral vascular disease status post aortobifemoral bypass and bilateral femoropopliteal bypass grafting.,3. Hypertension.,4. Diverticulosis.,5. Hypothyroidism.,6. Chronic renal insufficiency.,7. Status post open incision and drainage of an intestinal abscess at an unknown point.,DETERMINATION: , Status post right below-knee amputation.,OPERATIONS PERFORMED:,1. Extensive debridement of right below-knee amputation with debridement of skin, subcutaneous tissue, muscle, and bone on July 17, 2008.,2. Irrigation and debridement of right below-knee amputation wound on July 21, 2008, July 24, 2008, July 28, 2008, and August 1, 2008.,HISTORY OF PRESENT ILLNESS: , The patient is an 89-year-old gentleman with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations, and a right below-knee amputation in June 2008 following a thrombosis of his right femoropopliteal bypass graft. Following his amputation, he had poor wound healing. He presented to the ED with pain in his right lower extremity on July 9, 2008. Due to concern for infection at that time, he was started on oral Keflex and instructed to follow up with the Vascular Clinic as scheduled. At his follow-up appointment, it was decided to re-admit The patient for debridement and revision of his stump wound.,HOSPITAL COURSE:, Briefly, The patient underwent extensive debridement of his right below-knee amputation wound on July 17, 2008. He underwent debridement of skin, subcutaneous tissue, muscle, and bone to remove the necrotic tissue from the stump. A wound VAC. was also placed to help accelerate wound healing. The patient's postoperative course was complicated initially by acute blood-loss anemia, requiring blood transfusion. He returned to the OR on Monday, July 21, 2008 for irrigation and debridement of his right below-knee amputation and a wound VAC change. Again, on July 24, 2008, and then again on July 28, 2008, The patient returned to the operating room for irrigation and debridement of his wound and wound VAC change. Following his procedure on July 28, 2008, The patient began having recurrent episodes of diarrhea, prompting stool cultures and C. difficile assay to be sent. He was also started on Flagyl, empirically. C. difficile assay returned positive and the decision was made to continue Flagyl for a full 14-day course. On July 31, 2008, the patient began experiencing shortness of breath and wheezing after standing to be weighed. His vital signs remained stable. However, his oxygen saturation dropped to 93%, improving only to 97% after an addition of 2 liters by nasal cannula. A chest x-ray revealed bilateral pleural effusions and bibasilar atelectasis in addition to some pulmonary edema diffusely. The patient's IV fluids were decreased. He was given p.r.n. albuterol and infusion of Lasix, resulting in significant urine output. His symptoms of shortness of breath gradually improved. On August 1, 2008, he returned to the OR for final irrigation and debridement of his below-knee amputation. Again, a wound VAC was placed. Postoperatively, he did well. His Foley catheter was removed. His vital signs remained stable, and his respiratory status also remained stable. Arrangements were made for home health and wound VAC care upon discharge.,DISCHARGE CONDITION: , The patient is resting comfortably. He denies shortness of breath or chest pain. He has mild bibasilar wheezing, but breathing is otherwise nonlabored. All other exams normal.,DISCHARGE MEDICATIONS:,1. Acetaminophen 325 mg daily.,2. Albuterol 2 puffs every six hours as needed.,3. Vitamin C 500 mg one to two times daily.,4. Aspirin 81 mg daily.,5. Symbicort 1 puff every morning and 1 puff every evening.,6. Tums p.r.n.,7. Calcium 600 mg plus vitamin D daily.,8. Plavix 75 mg daily.,9. Clorazepate dipotassium 7.5 mg every six hours as needed.,10. Lexapro 10 mg daily at bedtime.,11. Hydrochlorothiazide 25 mg one-half tablet daily.,12. Ibuprofen 200 mg three pills as needed.,13. Imdur 30 mg daily.,14. Levoxyl 112 mcg daily.,15. Ativan 0.5 mg one-half tablet every six hours as needed.,16. Lopressor 50 mg one-half tablet twice daily.,17. Flagyl 500 mg every six hours for 10 days.,18. Multivitamin daily.,19. Nitrostat 0.4 mg to take as directed.,20. Omeprazole 20 mg daily.,21. Oxycodone-acetaminophen 5/325 mg every four to six hours as needed for pain.,22. Lyrica 25 mg daily at bedtime.,23. Zocor 40 mg one-half tablet daily at bedtime.

The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.

Discharge Summary

Discharge Summary - Peripheral vascular disease

mg, his, and, he, of

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] ADMITTING DIAGNOSIS:, A nonhealing right below-knee amputation.,DISCHARGE DIAGNOSIS:, A nonhealing right below-knee amputation.,SECONDARY DIAGNOSES:, Include:,1. Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies.,2. Peripheral vascular disease status post aortobifemoral bypass and bilateral femoropopliteal bypass grafting.,3. Hypertension.,4. Diverticulosis.,5. Hypothyroidism.,6. Chronic renal insufficiency.,7. Status post open incision and drainage of an intestinal abscess at an unknown point.,DETERMINATION: , Status post right below-knee amputation.,OPERATIONS PERFORMED:,1. Extensive debridement of right below-knee amputation with debridement of skin, subcutaneous tissue, muscle, and bone on July 17, 2008.,2. Irrigation and debridement of right below-knee amputation wound on July 21, 2008, July 24, 2008, July 28, 2008, and August 1, 2008.,HISTORY OF PRESENT ILLNESS: , The patient is an 89-year-old gentleman with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations, and a right below-knee amputation in June 2008 following a thrombosis of his right femoropopliteal bypass graft. Following his amputation, he had poor wound healing. He presented to the ED with pain in his right lower extremity on July 9, 2008. Due to concern for infection at that time, he was started on oral Keflex and instructed to follow up with the Vascular Clinic as scheduled. At his follow-up appointment, it was decided to re-admit The patient for debridement and revision of his stump wound.,HOSPITAL COURSE:, Briefly, The patient underwent extensive debridement of his right below-knee amputation wound on July 17, 2008. He underwent debridement of skin, subcutaneous tissue, muscle, and bone to remove the necrotic tissue from the stump. A wound VAC. was also placed to help accelerate wound healing. The patient's postoperative course was complicated initially by acute blood-loss anemia, requiring blood transfusion. He returned to the OR on Monday, July 21, 2008 for irrigation and debridement of his right below-knee amputation and a wound VAC change. Again, on July 24, 2008, and then again on July 28, 2008, The patient returned to the operating room for irrigation and debridement of his wound and wound VAC change. Following his procedure on July 28, 2008, The patient began having recurrent episodes of diarrhea, prompting stool cultures and C. difficile assay to be sent. He was also started on Flagyl, empirically. C. difficile assay returned positive and the decision was made to continue Flagyl for a full 14-day course. On July 31, 2008, the patient began experiencing shortness of breath and wheezing after standing to be weighed. His vital signs remained stable. However, his oxygen saturation dropped to 93%, improving only to 97% after an addition of 2 liters by nasal cannula. A chest x-ray revealed bilateral pleural effusions and bibasilar atelectasis in addition to some pulmonary edema diffusely. The patient's IV fluids were decreased. He was given p.r.n. albuterol and infusion of Lasix, resulting in significant urine output. His symptoms of shortness of breath gradually improved. On August 1, 2008, he returned to the OR for final irrigation and debridement of his below-knee amputation. Again, a wound VAC was placed. Postoperatively, he did well. His Foley catheter was removed. His vital signs remained stable, and his respiratory status also remained stable. Arrangements were made for home health and wound VAC care upon discharge.,DISCHARGE CONDITION: , The patient is resting comfortably. He denies shortness of breath or chest pain. He has mild bibasilar wheezing, but breathing is otherwise nonlabored. All other exams normal.,DISCHARGE MEDICATIONS:,1. Acetaminophen 325 mg daily.,2. Albuterol 2 puffs every six hours as needed.,3. Vitamin C 500 mg one to two times daily.,4. Aspirin 81 mg daily.,5. Symbicort 1 puff every morning and 1 puff every evening.,6. Tums p.r.n.,7. Calcium 600 mg plus vitamin D daily.,8. Plavix 75 mg daily.,9. Clorazepate dipotassium 7.5 mg every six hours as needed.,10. Lexapro 10 mg daily at bedtime.,11. Hydrochlorothiazide 25 mg one-half tablet daily.,12. Ibuprofen 200 mg three pills as needed.,13. Imdur 30 mg daily.,14. Levoxyl 112 mcg daily.,15. Ativan 0.5 mg one-half tablet every six hours as needed.,16. Lopressor 50 mg one-half tablet twice daily.,17. Flagyl 500 mg every six hours for 10 days.,18. Multivitamin daily.,19. Nitrostat 0.4 mg to take as directed.,20. Omeprazole 20 mg daily.,21. Oxycodone-acetaminophen 5/325 mg every four to six hours as needed for pain.,22. Lyrica 25 mg daily at bedtime.,23. Zocor 40 mg one-half tablet daily at bedtime. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Congestion & Cough - 5-month-Old

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a 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. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.

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.

Consult - History and Phy.

Congestion & Cough - 5-month-Old

she, her, was, and, history

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a 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. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed. [/TRANSCRIPTION] [TASK_OUTPUT] Congestion & Cough - 5-month-Old [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.52

CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode.

Questionable foreign body, right nose. Belly and back pain. Mild constipation.

General Medicine

Foreign Body - Right Nose

he, any, is, the, was

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode. [/TRANSCRIPTION] [TASK_OUTPUT] 0.52 [/TASK_OUTPUT] [DESCRIPTION] Questionable foreign body, right nose. Belly and back pain. Mild constipation. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

SOAP / Chart / Progress Notes

CHIEF COMPLAINT:, Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:, This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. ,General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.,Skin: Dry and flaky. ,CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen: Scaphoid.,Rectal: His prostate check was normal per Dr. Gill.,Neuro: Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1. Diabetes mellitus.,2. Neuropathy.,3. Status post cerebrovascular accident.,PLAN:, Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.

Sample progress note - Gen Med.

SOAP / Chart / Progress Notes

Gen Med Progress Note - 1

soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin,

he, his, we, has, and

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:, This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. ,General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.,Skin: Dry and flaky. ,CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen: Scaphoid.,Rectal: His prostate check was normal per Dr. Gill.,Neuro: Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1. Diabetes mellitus.,2. Neuropathy.,3. Status post cerebrovascular accident.,PLAN:, Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n. [/TRANSCRIPTION] [TASK_OUTPUT] SOAP / Chart / Progress Notes [/TASK_OUTPUT] [DESCRIPTION] Sample progress note - Gen Med. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Nephrology Consultation - 1

REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:, Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease. She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. Her creatinine both at XYZ Hospital and University of A was elevated at 2.4. I do not have the results from the prior years. A repeat creatinine on 08/16/06 was 2.3. The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. She had bladder studies a long time ago. She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. She denies any nonsteroidal antiinflammatory drug use. She denies any other over-the-counter medication use. She has chronic hypokalemia and has been on potassium supplements recently. She is unsure of the dose. ,PAST MEDICAL HISTORY: ,1. Hypertension on and off for years. She states she has been treated intermittently but lately has again been off medications.,2. Gastroesophageal reflux disease.,3. Gastritis.,4. Hiatal hernia.,5. H. pylori infection x3 in the last six months treated.,6. Chronic hypokalemia secondary to chronic diarrhea.,7. Recurrent admissions with nausea, vomiting, and dehydration. ,8. Renal cysts found on a CAT scan of the abdomen.,9. No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease. ,10. Stomach bypass surgery 1975 with chronic diarrhea.,11. History of UTI multiple times recently.,12. Questionable history of kidney stones.,13. History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14. Depression.,15. Diffuse degenerative disc disease of the spine.,16. Hypothyroidism.,17. History of iron deficiency anemia in the past. ,18. Hyperuricemia. ,19. History of small bowel resection with ulcerative fibroid. ,20. Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: , The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005. ,CURRENT MEDICATIONS: ,1. Nexium 40 mg q.d.,2. Synthroid 1 mg q.d. ,3. Potassium one q.d., unsure about the dose. ,4. No history of nonsteroidal drug use.,ALLERGIES:

Nephrology Consultation - Patient with renal failure.

Consult - History and Phy.

Nephrology Consultation - 1

she, in, the, of, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:, Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease. She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. Her creatinine both at XYZ Hospital and University of A was elevated at 2.4. I do not have the results from the prior years. A repeat creatinine on 08/16/06 was 2.3. The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. She had bladder studies a long time ago. She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. She denies any nonsteroidal antiinflammatory drug use. She denies any other over-the-counter medication use. She has chronic hypokalemia and has been on potassium supplements recently. She is unsure of the dose. ,PAST MEDICAL HISTORY: ,1. Hypertension on and off for years. She states she has been treated intermittently but lately has again been off medications.,2. Gastroesophageal reflux disease.,3. Gastritis.,4. Hiatal hernia.,5. H. pylori infection x3 in the last six months treated.,6. Chronic hypokalemia secondary to chronic diarrhea.,7. Recurrent admissions with nausea, vomiting, and dehydration. ,8. Renal cysts found on a CAT scan of the abdomen.,9. No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease. ,10. Stomach bypass surgery 1975 with chronic diarrhea.,11. History of UTI multiple times recently.,12. Questionable history of kidney stones.,13. History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14. Depression.,15. Diffuse degenerative disc disease of the spine.,16. Hypothyroidism.,17. History of iron deficiency anemia in the past. ,18. Hyperuricemia. ,19. History of small bowel resection with ulcerative fibroid. ,20. Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: , The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005. ,CURRENT MEDICATIONS: ,1. Nexium 40 mg q.d.,2. Synthroid 1 mg q.d. ,3. Potassium one q.d., unsure about the dose. ,4. No history of nonsteroidal drug use.,ALLERGIES: [/TRANSCRIPTION] [TASK_OUTPUT] Nephrology Consultation - 1 [/TASK_OUTPUT] [DESCRIPTION] Nephrology Consultation - Patient with renal failure. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis, nonperforated.,PROCEDURE PERFORMED:, Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia. The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp. The internal oblique fascia was similarly incised and its muscular fibers were similarly spread. The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident. Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound. After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties. The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix. The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp. The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline. The mesoappendix and cecum were examined for hemostasis which was present. The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was placed on the wound. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.

Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness.

Surgery

Appendectomy

surgery, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix,

the, was, and, with, were

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis, nonperforated.,PROCEDURE PERFORMED:, Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia. The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp. The internal oblique fascia was similarly incised and its muscular fibers were similarly spread. The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident. Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound. After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties. The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix. The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp. The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline. The mesoappendix and cecum were examined for hemostasis which was present. The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was placed on the wound. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness. [/DESCRIPTION] </s>

Summarize this medical transcription

MRI Brain, Carbon Monoxide poisoning.

CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.

MRI Brain, Carbon Monoxide poisoning.

Radiology

MRI Brain - CO poisoning

she, on, and, her, the

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity. [/TRANSCRIPTION] [TASK_OUTPUT] MRI Brain, Carbon Monoxide poisoning. [/TASK_OUTPUT] [DESCRIPTION] MRI Brain, Carbon Monoxide poisoning. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS:, History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:, IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding. He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE: ,The patient was prepped and draped in a left lateral decubitus position. The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum. He had an excellent prep. He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps. He tolerated the procedure well. There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon. His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since. Representative pictures were taken throughout the entire exam. There was no other evidence any problems. On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.

Total colonoscopy and polypectomy

Gastroenterology

Colonoscopy & Polypectomy - 1

gastroenterology, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,

he, the, and, had, left

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:, IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding. He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE: ,The patient was prepped and draped in a left lateral decubitus position. The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum. He had an excellent prep. He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps. He tolerated the procedure well. There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon. His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since. Representative pictures were taken throughout the entire exam. There was no other evidence any problems. On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Total colonoscopy and polypectomy [/DESCRIPTION] </s>

Extract key medical terms from this text

history, no, of, and, the

REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , 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. She is on multiple medications, unable to control the blood pressure. From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath. She complains of fatigue and tiredness. The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery. The patient is in intensive care unit.,CORONARY RISK FACTORS:, History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal. No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: ,No major surgery except for C-section.,MEDICATIONS:, Presently on Cardizem and metoprolol were discontinued. Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY:, Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: No congestive heart. No arrhythmia.,RESPIRATORY: No history of pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.,UROLOGIC: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins are flat.,LUNGS: Clear.,HEART: S1 and S2 regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes. Labs were noted. BUN and creatinine within normal limits.,IMPRESSION:,1. Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2. No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1. We will get an echocardiogram for assessment left ventricular function.,2. The patient will start on labetalol and hydralazine to see how see fairs.,3. Based on response to medication, we will make further adjustments. Discussed with the patient regarding plan of care, fully understands and consents for the same. All the questions answered in detail.

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.

Obstetrics / Gynecology

Preeclampsia

history, no, of, and, the

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , 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. She is on multiple medications, unable to control the blood pressure. From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath. She complains of fatigue and tiredness. The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery. The patient is in intensive care unit.,CORONARY RISK FACTORS:, History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal. No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: ,No major surgery except for C-section.,MEDICATIONS:, Presently on Cardizem and metoprolol were discontinued. Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY:, Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: No congestive heart. No arrhythmia.,RESPIRATORY: No history of pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.,UROLOGIC: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins are flat.,LUNGS: Clear.,HEART: S1 and S2 regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes. Labs were noted. BUN and creatinine within normal limits.,IMPRESSION:,1. Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2. No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1. We will get an echocardiogram for assessment left ventricular function.,2. The patient will start on labetalol and hydralazine to see how see fairs.,3. Based on response to medication, we will make further adjustments. Discussed with the patient regarding plan of care, fully understands and consents for the same. All the questions answered in detail. [/TRANSCRIPTION] [TASK_OUTPUT] history, no, of, and, the [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

MRI Brain - SLE & Stroke

CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision "greyed out" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were "unremarkable." Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly "unremarkable.",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: , ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or "gray outs" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.

MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.

Neurology

MRI Brain - SLE & Stroke

she, her, and, was, the

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision "greyed out" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were "unremarkable." Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly "unremarkable.",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: , ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or "gray outs" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96. [/TRANSCRIPTION] [TASK_OUTPUT] MRI Brain - SLE & Stroke [/TASK_OUTPUT] [DESCRIPTION] MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.68

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval.

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

Bariatrics

Bariatric Consult - Surgical Weight Loss - 1

bariatrics, elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,

she, is, history, mg, and

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval. [/TRANSCRIPTION] [TASK_OUTPUT] 0.68 [/TASK_OUTPUT] [DESCRIPTION] Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Alzheimer Disease

CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.

MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.

Radiology

Alzheimer Disease

radiology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory,

his, he, the, was, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions. [/TRANSCRIPTION] [TASK_OUTPUT] Alzheimer Disease [/TASK_OUTPUT] [DESCRIPTION] MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement. [/DESCRIPTION] </s>

Summarize this medical transcription

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.

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the 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.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.

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.

Ophthalmology

Phacoemulsification & Cataract Extraction - 2

ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,

the, was, then, and, using

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the 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.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] 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. [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Cardiovascular / Pulmonary

HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office 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. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.

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.

Cardiovascular / Pulmonary

Abnormal Stress Test

cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress

the, he, mg, with, and

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office 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. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images. [/TRANSCRIPTION] [TASK_OUTPUT] Cardiovascular / Pulmonary [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Extract key medical terms from this text

mg, the, was, her, patient

HISTORY:, A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs: Pulse of 90 and blood pressure 150/70.,Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest: Clinically clear.,Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1. Atherosclerotic heart disease, status post coronary artery bypass graft.,2. Valvular heart disease, status post aortic valve replacement.,3. Right arm arterial thrombosis, status post amputation right lower arm.,4. Hypothyroidism.,5. Uncontrolled diabetes mellitus, type 2.,6. Urinary tract infection.,7. Hypokalemia.,8. Heparin-induced thrombocytopenia.,9. Peripheral vascular occlusive disease.,10. Paroxysmal atrial fibrillation.,11. Hyperlipidemia.,12. Depression.,13. Carotid stenosis.

A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.

Consult - History and Phy.

Gen Med Consult - 43

consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic,

mg, the, was, her, patient

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] HISTORY:, A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs: Pulse of 90 and blood pressure 150/70.,Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest: Clinically clear.,Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1. Atherosclerotic heart disease, status post coronary artery bypass graft.,2. Valvular heart disease, status post aortic valve replacement.,3. Right arm arterial thrombosis, status post amputation right lower arm.,4. Hypothyroidism.,5. Uncontrolled diabetes mellitus, type 2.,6. Urinary tract infection.,7. Hypokalemia.,8. Heparin-induced thrombocytopenia.,9. Peripheral vascular occlusive disease.,10. Paroxysmal atrial fibrillation.,11. Hyperlipidemia.,12. Depression.,13. Carotid stenosis. [/TRANSCRIPTION] [TASK_OUTPUT] mg, the, was, her, patient [/TASK_OUTPUT] [DESCRIPTION] A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:

Ultrasound - a 22-year-old pregnant female.

Radiology

Ultrasound OB - 6

radiology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal,

normal, position, without, general, at

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix: [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Ultrasound - a 22-year-old pregnant female. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS:, Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001. On recent mammogram, she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia. Excisional biopsy was, therefore, recommended. Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38.,FINDINGS: , The area in question was excised. See details below. There was no gross evidence of malignancy. Final evaluation will per the permanent sections.,PROCEDURE:, Earlier today, the patient underwent a wire localization by Dr. A. She was then taken to the operating room and placed in the supine position. The left breast was prepped and draped in the usual sterile fashion.,A curvilinear incision was made in the upper outer quadrant to include a wire. The skin was incised. Hemostasis was achieved with cautery device where the breast tissue was excised around the wire. The specimens were marked for the long stitch laterally and short stitch superiorly, and fair length superficially. It was noted that the wire was fairly close to the superior deep aspect of the specimen. I, therefore, excised a new superior deep margin. This was performed with electrocautery device, the suture marks and new marks on the specimens. The main specimen itself was sent for ***** and gross inspection. The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections.,First, I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr. A. This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue. The specimens were then cut in serial fashion by Dr. Rust, the pathologist. There was no gross evidence of malignancy. As noted above, I previously excised the new superior deep margin and this was sent for permanent section. ,The wound was thoroughly irrigated and hemostasis was carefully achieved. The subdermal layer was closed with 4-0 PDS in simple interrupted fashion. The skin was closed with 4-0 Monocryl in a running subcuticular fashion. Steri-Strips and dressings were applied. All sponge, needle, and instrument counts were correct. The patient tolerated the procedure well and was taken to PACU in stable condition.,ESTIMATED BLOOD LOSS: , 5 mL.,COMPLICATIONS: , None.,DRAINS: , None.,SPECIMENS:, Left breast tissue and new superior deep margin.

Left excisional breast biopsy due to atypical ductal hyperplasia of left breast.

Surgery

Breast Biopsy - 1

surgery, breast, atypical ductal hyperplasia, breast biopsy, carcinoma in situ, excisional, hyperplasia, instrument counts, mammogram, needle, pathology, specimen, sponge, superior deep margin, ductal hyperplasia, deep margin, hemostasis, biopsy,

the, was, and, in, left

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001. On recent mammogram, she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia. Excisional biopsy was, therefore, recommended. Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38.,FINDINGS: , The area in question was excised. See details below. There was no gross evidence of malignancy. Final evaluation will per the permanent sections.,PROCEDURE:, Earlier today, the patient underwent a wire localization by Dr. A. She was then taken to the operating room and placed in the supine position. The left breast was prepped and draped in the usual sterile fashion.,A curvilinear incision was made in the upper outer quadrant to include a wire. The skin was incised. Hemostasis was achieved with cautery device where the breast tissue was excised around the wire. The specimens were marked for the long stitch laterally and short stitch superiorly, and fair length superficially. It was noted that the wire was fairly close to the superior deep aspect of the specimen. I, therefore, excised a new superior deep margin. This was performed with electrocautery device, the suture marks and new marks on the specimens. The main specimen itself was sent for ***** and gross inspection. The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections.,First, I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr. A. This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue. The specimens were then cut in serial fashion by Dr. Rust, the pathologist. There was no gross evidence of malignancy. As noted above, I previously excised the new superior deep margin and this was sent for permanent section. ,The wound was thoroughly irrigated and hemostasis was carefully achieved. The subdermal layer was closed with 4-0 PDS in simple interrupted fashion. The skin was closed with 4-0 Monocryl in a running subcuticular fashion. Steri-Strips and dressings were applied. All sponge, needle, and instrument counts were correct. The patient tolerated the procedure well and was taken to PACU in stable condition.,ESTIMATED BLOOD LOSS: , 5 mL.,COMPLICATIONS: , None.,DRAINS: , None.,SPECIMENS:, Left breast tissue and new superior deep margin. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Left excisional breast biopsy due to atypical ductal hyperplasia of left breast. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSIS:, Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:, Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , 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.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition.

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.

Surgery

Debridements

surgery, left lower extremity, debridement of wound, fasciotomies, debridement of muscle, vacuum-assisted closure systems, status post motorcycle accident, vacuum assisted closure systems, vacuum assisted closure, assisted closure systems, wound fasciotomies, fasciotomies debridement, vacuum assisted, closure systems, lower extremity, lateral compartments, anterior compartment, fasciotomy wounds, traumatic wound, wound, anterior, polytrauma, motorcycle, accident, contractile, vacuum, debridements, traumatic, muscle, fasciotomy, compartment

the, as, was, of, anterior

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:, Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , 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.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, was, with, and, procedure

PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well.

Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.

Surgery

Rhytidectomy & Blepharoplasty

surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

the, was, with, and, procedure

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well. [/TRANSCRIPTION] [TASK_OUTPUT] the, was, with, and, procedure [/TASK_OUTPUT] [DESCRIPTION] Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen. [/DESCRIPTION] </s>

Summarize this medical transcription

Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.

EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis.

Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.

Gastroenterology

CT Abdomen & Pelvis - 11

gastroenterology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,

the, and, of, there, is

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis. [/TRANSCRIPTION] [TASK_OUTPUT] Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast. [/TASK_OUTPUT] [DESCRIPTION] Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast. [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Orthopedic

REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.

Medical management, status post left total knee arthroplasty.

Orthopedic

Orthopedic Consult

no, is, history, the, neck

<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit. [/TRANSCRIPTION] [TASK_OUTPUT] Orthopedic [/TASK_OUTPUT] [DESCRIPTION] Medical management, status post left total knee arthroplasty. [/DESCRIPTION] </s>

Summarize this medical transcription

Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.

PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.

Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer.

Surgery

Port-A-Cath Insertion - 4

surgery, ovarian cancer, insertion, port-a-catheter, circumferential, counter incision, fluoroscopic, fluoroscopic guidance, guidewire, subclavian, superior vena cava, port a catheter, port, catheter, subcutaneously, vein

the, was, and, with, chest

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care. [/TRANSCRIPTION] [TASK_OUTPUT] Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer. [/TASK_OUTPUT] [DESCRIPTION] Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Blepharoplasty

BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings. Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized. This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures. The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin. This created a significant crisp, supratarsal fold. The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus. The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking. Then the skin muscle flap was elevated with sharp dissection. The fat was located and using a scissor the three eyelid compartments were opened. Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized. Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed. The suture line was sutured with interrupted 6-0 silk sutures. Once this was done the procedure was finished.,The patient left the OR in satisfactory condition. The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.

Blepharoplasty procedure

Cosmetic / Plastic Surgery

Blepharoplasty

cosmetic / plastic surgery, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

the, was, skin, upper, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings. Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized. This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures. The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin. This created a significant crisp, supratarsal fold. The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus. The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking. Then the skin muscle flap was elevated with sharp dissection. The fat was located and using a scissor the three eyelid compartments were opened. Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized. Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed. The suture line was sutured with interrupted 6-0 silk sutures. Once this was done the procedure was finished.,The patient left the OR in satisfactory condition. The patient was given 50 mg of Demerol IM with 25 mg of Phenergan. [/TRANSCRIPTION] [TASK_OUTPUT] Blepharoplasty [/TASK_OUTPUT] [DESCRIPTION] Blepharoplasty procedure [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.

Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.

Urology

Hydrocelectomy

urology, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,

the, was, then, and, placed

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

SUBJECTIVE: , 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. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.

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.

SOAP / Chart / Progress Notes

SOAP - Shortness of Breath

soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,

she, the, her, to, patient

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE: , 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. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

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Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.

Placement of Scott cannula, right lateral ventricle

Neurosurgery

Scott Cannula

neurosurgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

the, was, of, right, made

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Placement of Scott cannula, right lateral ventricle [/DESCRIPTION] </s>

Identify the medical specialty for this transcription

Surgery

PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case.

Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.

Surgery

Flap revision

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<s>[INSTRUCTION] Identify the medical specialty for this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case. [/TRANSCRIPTION] [TASK_OUTPUT] Surgery [/TASK_OUTPUT] [DESCRIPTION] Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, he became confused and he eloped from the unit. When he was found, he became combative. This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly. There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital. Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications. He reports feeling fine currently, denying any complaints. The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment. She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around. However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety. He also denies any hallucinations or delusions. He endorses problems with insomnia. At home, he takes temazepam. His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:, He denies any prior psychiatric treatment or intervention. However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia. During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily. He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1. Heart transplant in 1997.,2. History of abdominal aortic aneurysm repair.,3. Diverticulitis.,4. Cholecystectomy.,5. Benign prostatic hypertrophy.,ALLERGIES:, MORPHINE AND DEMEROL.,MEDICATIONS:,1. Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2. Imodium 2 mg p.o. p.r.n., loose stool.,3. Calcium carbonate with vitamin D 500 mg b.i.d.,4. Prednisone 5 mg p.o. daily.,5. Bactrim DS Monday, Wednesday, and Friday.,6. Flomax 0.4 mg p.o. daily.,7. Robitussin 5 mL every 6 hours as needed for cough.,8. Rapamune 2 mg p.o. daily.,9. Zoloft 50 mg p.o. daily.,10. B vitamin complex daily.,11. Colace 100 mg b.i.d.,12. Lipitor 20 mg p.o. q.h.s.,13. Plavix 75 mg p.o. daily.,14. Aricept 5 mg p.o. daily.,15. Pepcid 20 mg p.o. daily.,16. Norvasc 5 mg p.o. daily.,17. Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:, The patient is a retired paster and missionary to Mexico. He is still actively involved in his church. He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:, He is an average-sized white male, casually dressed, with wife and son at bedside. He is pleasant and cooperative with good eye contact. He presents with paucity of speech content; however, with regular rate and rhythm. He is tremulous which is worse with posturing also some increased motor tone noted. There is no evidence of psychomotor agitation or retardation. His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content. His thoughts are circumstantial but logical. He defers most of his responses to his wife. There is no evidence of suicidal or homicidal ideations. No presence of paranoid or bizarre delusions. He denies any perceptual abnormalities and does not appear to be responding to internal stimuli. His attention is fair and his concentration impaired. He is oriented x3 and his insight is fair. On mini-mental status examination, he has scored 22 out of 30. He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s. On category fluency, he was able to name 17 animals in one minute. He was unable to draw clock showing 2 minutes after 10. His judgment seems limited.,LABORATORY DATA:, Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000. Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:, MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1. Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2. Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3. Depressive disorder, not otherwise specified.

Psychiatric Consultation of patient with altered mental status.

Consult - History and Phy.

Psych Consult - Altered Mental Status

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<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, he became confused and he eloped from the unit. When he was found, he became combative. This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly. There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital. Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications. He reports feeling fine currently, denying any complaints. The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment. She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around. However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety. He also denies any hallucinations or delusions. He endorses problems with insomnia. At home, he takes temazepam. His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:, He denies any prior psychiatric treatment or intervention. However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia. During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily. He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1. Heart transplant in 1997.,2. History of abdominal aortic aneurysm repair.,3. Diverticulitis.,4. Cholecystectomy.,5. Benign prostatic hypertrophy.,ALLERGIES:, MORPHINE AND DEMEROL.,MEDICATIONS:,1. Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2. Imodium 2 mg p.o. p.r.n., loose stool.,3. Calcium carbonate with vitamin D 500 mg b.i.d.,4. Prednisone 5 mg p.o. daily.,5. Bactrim DS Monday, Wednesday, and Friday.,6. Flomax 0.4 mg p.o. daily.,7. Robitussin 5 mL every 6 hours as needed for cough.,8. Rapamune 2 mg p.o. daily.,9. Zoloft 50 mg p.o. daily.,10. B vitamin complex daily.,11. Colace 100 mg b.i.d.,12. Lipitor 20 mg p.o. q.h.s.,13. Plavix 75 mg p.o. daily.,14. Aricept 5 mg p.o. daily.,15. Pepcid 20 mg p.o. daily.,16. Norvasc 5 mg p.o. daily.,17. Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:, The patient is a retired paster and missionary to Mexico. He is still actively involved in his church. He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:, He is an average-sized white male, casually dressed, with wife and son at bedside. He is pleasant and cooperative with good eye contact. He presents with paucity of speech content; however, with regular rate and rhythm. He is tremulous which is worse with posturing also some increased motor tone noted. There is no evidence of psychomotor agitation or retardation. His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content. His thoughts are circumstantial but logical. He defers most of his responses to his wife. There is no evidence of suicidal or homicidal ideations. No presence of paranoid or bizarre delusions. He denies any perceptual abnormalities and does not appear to be responding to internal stimuli. His attention is fair and his concentration impaired. He is oriented x3 and his insight is fair. On mini-mental status examination, he has scored 22 out of 30. He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s. On category fluency, he was able to name 17 animals in one minute. He was unable to draw clock showing 2 minutes after 10. His judgment seems limited.,LABORATORY DATA:, Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000. Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:, MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1. Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2. Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3. Depressive disorder, not otherwise specified. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Psychiatric Consultation of patient with altered mental status. [/DESCRIPTION] </s>

Extract key medical terms from this text

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PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed. ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation. Digital rectal examination was performed, which showed no masses, and a boggy prostate. The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.

The patient with a recent change in bowel function and hematochezia.

Gastroenterology

Colonoscopy with Biopsy - 1

gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,

the, and, in, he, was

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREPROCEDURE DIAGNOSIS:, Change in bowel function.,POSTPROCEDURE DIAGNOSIS:, Proctosigmoiditis.,PROCEDURE PERFORMED:, Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable. ,INDICATIONS:, The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed. ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation. Digital rectal examination was performed, which showed no masses, and a boggy prostate. The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories. [/TRANSCRIPTION] [TASK_OUTPUT] the, and, in, he, was [/TASK_OUTPUT] [DESCRIPTION] The patient with a recent change in bowel function and hematochezia. [/DESCRIPTION] </s>

Extract key medical terms from this text

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PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.

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.

Surgery

Cheek-Neck Facelift

surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,

the, and, was, area, in

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] the, and, was, area, in [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.

Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.

Ophthalmology

Bilateral Upper Lid Blepharoplasty

ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis

the, and, upper, was, of

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis. [/DESCRIPTION] </s>

Extract original key medical terms from this text

radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,

INDICATIONS:, Peripheral vascular disease with claudication.,RIGHT:, ,1. Normal arterial imaging of right lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic.,4. Ankle brachial index is 0.96.,LEFT:,1. Normal arterial imaging of left lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4. Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.

Arterial imaging of bilateral lower extremities.

Radiology

Arterial Imaging

radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,

is, normal, lower, right, left

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] INDICATIONS:, Peripheral vascular disease with claudication.,RIGHT:, ,1. Normal arterial imaging of right lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic.,4. Ankle brachial index is 0.96.,LEFT:,1. Normal arterial imaging of left lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4. Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities. [/TRANSCRIPTION] [TASK_OUTPUT] radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial, [/TASK_OUTPUT] [DESCRIPTION] Arterial imaging of bilateral lower extremities. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, of, left, through, was

EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.

CT of abdomen with and without contrast. CT-guided needle placement biopsy.

Radiology

CT-Guided Needle Placement Biopsy

radiology, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct guided, renal

the, of, left, through, was

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described. [/TRANSCRIPTION] [TASK_OUTPUT] the, of, left, through, was [/TASK_OUTPUT] [DESCRIPTION] CT of abdomen with and without contrast. CT-guided needle placement biopsy. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Non-Hodgkin lymphoma Followup

CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.,3. History of congestive heart failure.,4. History of schwannoma resection. It was resected from T12 to L1 in 1991.,5. He has chronic obstruction of his inferior vena cava.,6. Recurrent lower extremity cellulitis.,SOCIAL HISTORY: ,He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:

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.

SOAP / Chart / Progress Notes

Non-Hodgkin lymphoma Followup

he, his, mg, history, of

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.,3. History of congestive heart failure.,4. History of schwannoma resection. It was resected from T12 to L1 in 1991.,5. He has chronic obstruction of his inferior vena cava.,6. Recurrent lower extremity cellulitis.,SOCIAL HISTORY: ,He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT: [/TRANSCRIPTION] [TASK_OUTPUT] Non-Hodgkin lymphoma Followup [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.61

PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007. The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago. The patient had shortening in arms, noted in both bones. The parents opted for surgical stabilization with nailing. This was performed one month ago on return visit. His ulnar nail was quite prominent underneath the skin. It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother. Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting. All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL: ,The patient was seen in the operative room, placed supine on operating room table. General anesthesia was then administered. The patient was given Ancef preoperatively. The left elbow was prepped and draped in a standard surgical fashion. A small incision was made over the palm with K-wire. This was removed without incident. The wound was irrigated. The bursitis was curetted. Wounds closed using #4-0 Monocryl. The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril. Please note the area infiltrated with 0.25% Marcaine. The patient was then placed in a long-arm cast. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: ,The patient will maintain the cast for 3 more weeks. Intraoperative nail was given to the mother. The patient to take Tylenol with Codeine as needed. All questions were answered.,

Hardware removal, right ulnar

Surgery

Hardware Removal - Ulnar

surgery, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar,

the, was, patient, in, and

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007. The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago. The patient had shortening in arms, noted in both bones. The parents opted for surgical stabilization with nailing. This was performed one month ago on return visit. His ulnar nail was quite prominent underneath the skin. It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother. Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting. All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL: ,The patient was seen in the operative room, placed supine on operating room table. General anesthesia was then administered. The patient was given Ancef preoperatively. The left elbow was prepped and draped in a standard surgical fashion. A small incision was made over the palm with K-wire. This was removed without incident. The wound was irrigated. The bursitis was curetted. Wounds closed using #4-0 Monocryl. The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril. Please note the area infiltrated with 0.25% Marcaine. The patient was then placed in a long-arm cast. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: ,The patient will maintain the cast for 3 more weeks. Intraoperative nail was given to the mother. The patient to take Tylenol with Codeine as needed. All questions were answered., [/TRANSCRIPTION] [TASK_OUTPUT] 0.61 [/TASK_OUTPUT] [DESCRIPTION] Hardware removal, right ulnar [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides. There were no complications.

Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.

Pain Management

Epidurogram

pain management, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle

the, was, and, right, to

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides. There were no complications. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.56

PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.

Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.

Hematology - Oncology

Needle Localized Excision - Breast Neoplasm

hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast

the, was, and, with, of

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED: ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS: ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well. [/TRANSCRIPTION] [TASK_OUTPUT] 0.56 [/TASK_OUTPUT] [DESCRIPTION] Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast. [/DESCRIPTION] </s>

Summarize this medical transcription

Open reduction, nasal fracture with nasal septoplasty.

PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL.

Open reduction, nasal fracture with nasal septoplasty.

Surgery

Nasal Septoplasty

surgery, nasal fracture, deviated nasal septum, nasal septoplasty, nasal bones, ethmoid plate, cartilaginous septum, nasal bone, maxillary crest, septum, nasal, fracture, maxillary, cartilaginous, crest,

the, was, and, left, with

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL. [/TRANSCRIPTION] [TASK_OUTPUT] Open reduction, nasal fracture with nasal septoplasty. [/TASK_OUTPUT] [DESCRIPTION] Open reduction, nasal fracture with nasal septoplasty. [/DESCRIPTION] </s>

Summarize this medical transcription

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.

PREOPERATIVE DIAGNOSIS: , Biliary colic.

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.

Gastroenterology

Laparoscopic Cholecystectomy - 5

gastroenterology, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic,

diagnosis, 10, after, all, also

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Biliary colic. [/TRANSCRIPTION] [TASK_OUTPUT] 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. [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.

The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.

Consult - History and Phy.

Adult Hydrocephalus

she, her, and, is, has

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.44

PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.

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.

Surgery

Flexible Fiberoptic Bronchoscopy

surgery, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope

the, was, and, of, right

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.44 [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Inguinal Herniorrhaphy - 2

PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,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. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.

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.

Urology

Inguinal Herniorrhaphy - 2

urology, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery

the, was, using, and, then

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,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. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Inguinal Herniorrhaphy - 2 [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.66

CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of "swollen left foot." These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.

Left Iliopsoas hematoma. Gait difficulty.

Consult - History and Phy.

Iliopsoas Hematoma - 1

she, and, left, of, her

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of "swollen left foot." These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome. [/TRANSCRIPTION] [TASK_OUTPUT] 0.66 [/TASK_OUTPUT] [DESCRIPTION] Left Iliopsoas hematoma. Gait difficulty. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Echocardiogram

REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Mild mitral regurgitation.,3. Mild tricuspid regurgitation.

Echocardiogram with color flow and conventional Doppler interrogation.

Cardiovascular / Pulmonary

Echocardiogram

cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation,

the, is, normal, are, left

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Mild mitral regurgitation.,3. Mild tricuspid regurgitation. [/TRANSCRIPTION] [TASK_OUTPUT] Echocardiogram [/TASK_OUTPUT] [DESCRIPTION] Echocardiogram with color flow and conventional Doppler interrogation. [/DESCRIPTION] </s>

Summarize this medical transcription

MRI Head W&WO Contrast.

EXAM:, MRI Head W&WO Contrast.,REASON FOR EXAM:, Dyspnea.,COMPARISON:, None. ,TECHNIQUE:, MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist). ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement. There are no diffusion weighted signal abnormalities. There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal. The ventricles and sulci are prominent, but proportionate. Per T2 weighted sequence, there is no hyperdense vascularity. There are no calvarial signal abnormalities. There is no significant mastoid air cell fluid. No significant sinus mucosal disease per MRI.,IMPRESSION:,1. No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses. ,2. No evidence for acute infarction. ,3. Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4. Diffuse cortical volume loss, consistent with patient's age. ,5. Preliminary report was issued at the time of dictation. ,

MRI Head W&WO Contrast.

Radiology

MRI Head

radiology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri

no, are, there, of, the

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] EXAM:, MRI Head W&WO Contrast.,REASON FOR EXAM:, Dyspnea.,COMPARISON:, None. ,TECHNIQUE:, MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist). ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement. There are no diffusion weighted signal abnormalities. There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal. The ventricles and sulci are prominent, but proportionate. Per T2 weighted sequence, there is no hyperdense vascularity. There are no calvarial signal abnormalities. There is no significant mastoid air cell fluid. No significant sinus mucosal disease per MRI.,IMPRESSION:,1. No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses. ,2. No evidence for acute infarction. ,3. Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4. Diffuse cortical volume loss, consistent with patient's age. ,5. Preliminary report was issued at the time of dictation. , [/TRANSCRIPTION] [TASK_OUTPUT] MRI Head W&WO Contrast. [/TASK_OUTPUT] [DESCRIPTION] MRI Head W&WO Contrast. [/DESCRIPTION] </s>

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Flex Sig

MEDICATIONS:, None.,DESCRIPTION OF THE PROCEDURE:, After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn. The mucosa appeared normal. Retroflex examination of the rectum was normal.

Flexible Sigmoidoscopy.

Gastroenterology

Flex Sig

gastroenterology, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

the, was, normal, and, of

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] MEDICATIONS:, None.,DESCRIPTION OF THE PROCEDURE:, After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn. The mucosa appeared normal. Retroflex examination of the rectum was normal. [/TRANSCRIPTION] [TASK_OUTPUT] Flex Sig [/TASK_OUTPUT] [DESCRIPTION] Flexible Sigmoidoscopy. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament

PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , 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.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. Bipolar electrocautery was used to maintain meticulous hemostasis. I then performed an antebrachial fasciotomy proximally. I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. Great care was taken with placement. A good plane was positively identified. I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me. I had my thumb on the distal aspect of the transverse carpal ligament. I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. I pulled back and cut and partially tightened the transverse carpal ligament. I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. I then checked to make sure this was properly performed and then cut the proximal aspect. I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time. Great care was taken and at no point was there any longitudinal structure cut. Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut. Following this, I irrigated and closed the skin. The patient was dressed and sent to the recovery room in good condition.

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.

Surgery

Carpal Tunnel Release - Endoscopic

surgery, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament

the, and, was, then, to

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , 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.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. Bipolar electrocautery was used to maintain meticulous hemostasis. I then performed an antebrachial fasciotomy proximally. I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. Great care was taken with placement. A good plane was positively identified. I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me. I had my thumb on the distal aspect of the transverse carpal ligament. I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. I pulled back and cut and partially tightened the transverse carpal ligament. I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. I then checked to make sure this was properly performed and then cut the proximal aspect. I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time. Great care was taken and at no point was there any longitudinal structure cut. Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut. Following this, I irrigated and closed the skin. The patient was dressed and sent to the recovery room in good condition. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Extract original key medical terms from this text

orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,

ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:, Stable.,PROCEDURES PERFORMED:, Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE: ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT, she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks.

Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.

Orthopedic

Knee Arthroplasty - Discharge Summary

orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,

the, patient, to, right, is

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:, Stable.,PROCEDURES PERFORMED:, Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE: ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT, she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks. [/TRANSCRIPTION] [TASK_OUTPUT] orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty, [/TASK_OUTPUT] [DESCRIPTION] Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

HISTORY OF PRESENT ILLNESS:, 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. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not gotten worse recently and there is no numbness in her toes. She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. GENERAL: She is a middle-aged white female, not in any distress. HEENT: No lymphadenopathy or mucositis. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: No focal deficits noted. PELVIC: Normal-appearing external genitalia. Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. No local or distant metastasis. Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy. She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1. Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2. The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3. The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4. The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,

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.

SOAP / Chart / Progress Notes

Uterine Papillary Serous Carcinoma

soap / chart / progress notes, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma,

is, her, and, she, or

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS:, 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. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not gotten worse recently and there is no numbness in her toes. She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. GENERAL: She is a middle-aged white female, not in any distress. HEENT: No lymphadenopathy or mucositis. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: No focal deficits noted. PELVIC: Normal-appearing external genitalia. Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. No local or distant metastasis. Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy. She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1. Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2. The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3. The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4. The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent., [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well.

Left below-the-knee amputation. Dressing change, right foot.

Surgery

Knee Amputation

surgery, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped,

the, and, was, with, left

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Left below-the-knee amputation. Dressing change, right foot. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.45

PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Injury to the adjacent viscera.,6. Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty. The patient was shaved, prepped, and draped using the usual sterile technique. A sterile 16-French Foley catheter was then placed with clear urine drained. A midline infraumbilical incision was performed by using a #10 scalpel blade. The rectus fascia and the subcutaneous space were opened by using the Bovie. Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. A Bookwalter retractor was then placed. The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors. Opening was enlarged by using sharp dissection. Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion. With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie. Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors. The urethra could then be easily identified. Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors. This exposed the blue Foley catheter. Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture. Six of these were placed evenly spaced out anteriorly to posteriorly. The Foley catheter was then removed. This allowed for better traction of the prostate laterally. Lateral pelvic fascia was opened bilaterally. This effectively released the neurovascular bundle from the apex to the base of the prostate. Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. The prostate was then dissected from laterally to medially from this opening in the perirectal fat. The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. Maximal length of ureteral stump was preserved. The prostate was carefully lifted cephalad by using gentle traction with fine forceps. The prostate was easily dissected off the perirectal fat using sharp dissection only. Absolutely, no traction to the neurovascular bundle was evident at any point in time. The dissection was carried out easily until the seminal vesicles could be visualized. The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. The bladder neck was then dissected out by using a bladder neck dissection method. Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. This was developed without any difficulty. Both vas deferens were identified, hemoclipped and transected. The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. About two-thirds of the seminal vesicles were able to be removed. The tip was left behind. Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. This was performed on the left side and then the right side. This completely freed the prostate. The prostate was sent for permanent section. The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures. The mucosa of the bladder neck was everted by using 4-0 chromic sutures. Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. This was performed by using a French ***** needle. A 20-French Foley catheter was then inserted and the sutures were sequentially tied down. A 15 mL of sterile water was inflated to balloon. The bladder anastomosis to the urethra was performed without any difficulty. A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region. All instrument counts, lap counts, and latex were verified twice prior to the closure. The rectus fascia was closed in running fashion using #1 PDS. Subcutaneous space was closed by using 2-0 Vicryl sutures. The skin was reapproximated by using metallic clips. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

Radical retropubic nerve-sparing prostatectomy without lymph node dissection.

Surgery

Prostatectomy - Nerve Sparing

surgery, prostate cancer, foley catheter, gleason, psa, prostate, adenocarcinoma, bladder neck, core biopsy, figure-of-eight, lymph node dissection, nerve-sparing, prostatectomy, rectus fascia, retropubic, bladder neck dissection, dorsal vein complex, nerve sparing, perirectal fat, seminal vesicles, sutures, bladder, urethra, posteriorly, seminal, vesicles, fascia, neck, dissection,

the, using, was, by, to

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Injury to the adjacent viscera.,6. Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty. The patient was shaved, prepped, and draped using the usual sterile technique. A sterile 16-French Foley catheter was then placed with clear urine drained. A midline infraumbilical incision was performed by using a #10 scalpel blade. The rectus fascia and the subcutaneous space were opened by using the Bovie. Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. A Bookwalter retractor was then placed. The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors. Opening was enlarged by using sharp dissection. Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion. With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie. Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors. The urethra could then be easily identified. Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors. This exposed the blue Foley catheter. Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture. Six of these were placed evenly spaced out anteriorly to posteriorly. The Foley catheter was then removed. This allowed for better traction of the prostate laterally. Lateral pelvic fascia was opened bilaterally. This effectively released the neurovascular bundle from the apex to the base of the prostate. Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. The prostate was then dissected from laterally to medially from this opening in the perirectal fat. The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. Maximal length of ureteral stump was preserved. The prostate was carefully lifted cephalad by using gentle traction with fine forceps. The prostate was easily dissected off the perirectal fat using sharp dissection only. Absolutely, no traction to the neurovascular bundle was evident at any point in time. The dissection was carried out easily until the seminal vesicles could be visualized. The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. The bladder neck was then dissected out by using a bladder neck dissection method. Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. This was developed without any difficulty. Both vas deferens were identified, hemoclipped and transected. The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. About two-thirds of the seminal vesicles were able to be removed. The tip was left behind. Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. This was performed on the left side and then the right side. This completely freed the prostate. The prostate was sent for permanent section. The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures. The mucosa of the bladder neck was everted by using 4-0 chromic sutures. Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. This was performed by using a French ***** needle. A 20-French Foley catheter was then inserted and the sutures were sequentially tied down. A 15 mL of sterile water was inflated to balloon. The bladder anastomosis to the urethra was performed without any difficulty. A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region. All instrument counts, lap counts, and latex were verified twice prior to the closure. The rectus fascia was closed in running fashion using #1 PDS. Subcutaneous space was closed by using 2-0 Vicryl sutures. The skin was reapproximated by using metallic clips. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.45 [/TASK_OUTPUT] [DESCRIPTION] Radical retropubic nerve-sparing prostatectomy without lymph node dissection. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.

Left axillary lymph node excisional biopsy. Left axillary adenopathy.

Hematology - Oncology

Lymph Node Excisional Biopsy

hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy

the, was, her, she, and

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Left axillary lymph node excisional biopsy. Left axillary adenopathy. [/DESCRIPTION] </s>

Summarize this medical transcription

A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.

DISCHARGE DATE: MM/DD/YYYY,HISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE: Mr. ABC presented to the Day Hospital in anticipation for Urology surgery. On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained. A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. In addition, inducible ischemia seen in the inferior lateral septum. Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease. The RCA, proximal was 95% stenosed and the distal 80% stenosed. The mid LAD was 85% stenosed and the distal LAD was 85% stenosed. There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%. Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ. Mr. ABC had a noncomplicated post-intervention hospital course. He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS: Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Obese, soft, nontender. Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN: Dry and intact, no bruit, no ecchymosis, no hematoma. Distal pulses are intact.,DISCHARGE LABS: CBC: White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1. BMP: Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211. Lipid profile: Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1. On MM/DD/YYYY, cardiac MRI adenosine stress.,2. On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS: Mr. ABC is discharged home. He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. He should follow post-coronary artery intervention restrictions. He should not lift greater than 10 pounds for seven days. He should not drive for two days. He should not immerse in water for two weeks. Groin site care reviewed with patient prior to being discharged home. He should check groin for bleeding, edema, and signs of infection. Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him. He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1. Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2. Bladder cancer.,3. Diabetes.,4. Dyslipidemia.,5. Hypertension.,6. Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7. Multiple resections of the bladder tumor.,8. Distant history of appendectomy.,9. Distant history of ankle surgery.

A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.

Discharge Summary

Discharge Summary - 6

discharge summary, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary,

to, he, artery, mm, the

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] DISCHARGE DATE: MM/DD/YYYY,HISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE: Mr. ABC presented to the Day Hospital in anticipation for Urology surgery. On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained. A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. In addition, inducible ischemia seen in the inferior lateral septum. Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease. The RCA, proximal was 95% stenosed and the distal 80% stenosed. The mid LAD was 85% stenosed and the distal LAD was 85% stenosed. There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%. Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ. Mr. ABC had a noncomplicated post-intervention hospital course. He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS: Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Obese, soft, nontender. Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN: Dry and intact, no bruit, no ecchymosis, no hematoma. Distal pulses are intact.,DISCHARGE LABS: CBC: White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1. BMP: Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211. Lipid profile: Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1. On MM/DD/YYYY, cardiac MRI adenosine stress.,2. On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS: Mr. ABC is discharged home. He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. He should follow post-coronary artery intervention restrictions. He should not lift greater than 10 pounds for seven days. He should not drive for two days. He should not immerse in water for two weeks. Groin site care reviewed with patient prior to being discharged home. He should check groin for bleeding, edema, and signs of infection. Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him. He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1. Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2. Bladder cancer.,3. Diabetes.,4. Dyslipidemia.,5. Hypertension.,6. Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7. Multiple resections of the bladder tumor.,8. Distant history of appendectomy.,9. Distant history of ankle surgery. [/TRANSCRIPTION] [TASK_OUTPUT] A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. [/TASK_OUTPUT] [DESCRIPTION] A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.43

PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition.

Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.

Surgery

Laparoscopy, Laparotomy, & Cholecystectomy

surgery, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder

the, was, and, of, this

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] 0.43 [/TASK_OUTPUT] [DESCRIPTION] Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,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.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication.

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.

Cardiovascular / Pulmonary

Tracheostomy

cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid,

the, and, was, of, to

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,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.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Summarize this medical transcription

MRI cervical spine.

EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.

MRI cervical spine.

Radiology

MRI Cervical Spine - 1

radiology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,

with, normal, the, there, is

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord. [/TRANSCRIPTION] [TASK_OUTPUT] MRI cervical spine. [/TASK_OUTPUT] [DESCRIPTION] MRI cervical spine. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2.

Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.

Orthopedic

Subcutaneous Transposition of Ulnar Nerve

orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel

diagnosis, right, 10, after, all

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

TESTICULAR ULTRASOUND,REASON FOR EXAM: ,Left testicular swelling for one day.,FINDINGS: ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side.,IMPRESSION:,1. Hypervascularity of the left epididymis compatible with left epididymitis.,2. Bilateral hydroceles.

Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.

Radiology

Testicular Ultrasound

radiology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular,

left, the, is, normal, mm

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] TESTICULAR ULTRASOUND,REASON FOR EXAM: ,Left testicular swelling for one day.,FINDINGS: ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side.,IMPRESSION:,1. Hypervascularity of the left epididymis compatible with left epididymitis.,2. Bilateral hydroceles. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Left testicular swelling for one day. Testicular Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Psychiatric Consult

HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. 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.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.

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.

Consult - History and Phy.

Psychiatric Consult

consult - history and phy., noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis,

he, of, the, is, his

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. 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.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this. [/TRANSCRIPTION] [TASK_OUTPUT] Psychiatric Consult [/TASK_OUTPUT] [DESCRIPTION] 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. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Pain Management Consult - 1

Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero.

Pain management for post-laminectomy low back syndrome and radiculopathy.

Consult - History and Phy.

Pain Management Consult - 1

consult - history and phy., pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,

the, of, he, and, is

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero. [/TRANSCRIPTION] [TASK_OUTPUT] Pain Management Consult - 1 [/TASK_OUTPUT] [DESCRIPTION] Pain management for post-laminectomy low back syndrome and radiculopathy. [/DESCRIPTION] </s>

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Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 04/26/2007. She had a history of open heart surgery at 11 months' of age. She presented with severe anterior caries with most likely dental extractions needed. Due to her young age, I felt that she would be best served in the safety of the hospital operating room. After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION: ,This child was brought to Hospital Day Surgery and is accompanied by her mother. There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An angiocatheter was placed in the left hand and an IV was started. The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond the tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography. After the radiographs were taken, the lead shield was removed. Prophylaxis was then performed using prophy cup and fluoridated prophy paste. The teeth were then rinsed well and the patient's oral cavity was suctioned clean. Clinical and radiographic examinations followed and areas of decay were noted. During the restorative phase, these areas of decay were entered into and removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries was removed and was confirmed upon reaching hard, firm sounding dentin. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS: ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental caries were present on the following teeth: Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries. The remainder of her teeth and soft tissues were within normal limits. The following restorations and procedures were performed: Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. They will contact to my office in the event of immediate postoperative complications. After full recovery, she was discharged from the recovery room in the care of her mother.

Full mouth dental rehabilitation in the operative room under general anesthesia.

Dentistry

Full Mouth Dental Rehabilitation - 2

dentistry, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth,

the, and, was, were, of

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 04/26/2007. She had a history of open heart surgery at 11 months' of age. She presented with severe anterior caries with most likely dental extractions needed. Due to her young age, I felt that she would be best served in the safety of the hospital operating room. After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION: ,This child was brought to Hospital Day Surgery and is accompanied by her mother. There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An angiocatheter was placed in the left hand and an IV was started. The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond the tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography. After the radiographs were taken, the lead shield was removed. Prophylaxis was then performed using prophy cup and fluoridated prophy paste. The teeth were then rinsed well and the patient's oral cavity was suctioned clean. Clinical and radiographic examinations followed and areas of decay were noted. During the restorative phase, these areas of decay were entered into and removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries was removed and was confirmed upon reaching hard, firm sounding dentin. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS: ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental caries were present on the following teeth: Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries. The remainder of her teeth and soft tissues were within normal limits. The following restorations and procedures were performed: Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. They will contact to my office in the event of immediate postoperative complications. After full recovery, she was discharged from the recovery room in the care of her mother. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Full mouth dental rehabilitation in the operative room under general anesthesia. [/DESCRIPTION] </s>

Extract original key medical terms from this text

nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.

Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.

Nephrology

Internal Jugular Vein Catheter Insertion

nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

the, was, used, and, right

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax. [/TRANSCRIPTION] [TASK_OUTPUT] nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein [/TASK_OUTPUT] [DESCRIPTION] Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Bariatric Consult - Surgical Weight Loss - 1

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval.

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

Bariatrics

Bariatric Consult - Surgical Weight Loss - 1

bariatrics, elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,

she, is, history, mg, and

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval. [/TRANSCRIPTION] [TASK_OUTPUT] Bariatric Consult - Surgical Weight Loss - 1 [/TASK_OUTPUT] [DESCRIPTION] Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, of, right, and, mm

EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above.

Frontal and lateral views of the hip and pelvis.

Radiology

Slipped Capital Femoral Epiphysis (SCFE)

radiology, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

the, of, right, and, mm

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above. [/TRANSCRIPTION] [TASK_OUTPUT] the, of, right, and, mm [/TASK_OUTPUT] [DESCRIPTION] Frontal and lateral views of the hip and pelvis. [/DESCRIPTION] </s>

Summarize this medical transcription

The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

Consult - History and Phy.

Abdominal Pain - Consult

and, she, the, history, of

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup. [/TRANSCRIPTION] [TASK_OUTPUT] The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. [/TASK_OUTPUT] [DESCRIPTION] The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.61

PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.

Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.

Ophthalmology

YAG Laser Capsulotomy

ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

the, were, was, patient, procedure

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions. [/TRANSCRIPTION] [TASK_OUTPUT] 0.61 [/TASK_OUTPUT] [DESCRIPTION] Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye. [/DESCRIPTION] </s>

Summarize this medical transcription

Bilateral vasovasostomy surgery sample.

Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. This incision was carried down to the area of the previous vasectomy. A towel clip was placed around this. Next the scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the vas ends were pulled together by tying the sutures. A good reapproximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed.

Bilateral vasovasostomy surgery sample.

Surgery

Bilateral Vasovasostomy

surgery, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

the, was, and, were, to

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. This incision was carried down to the area of the previous vasectomy. A towel clip was placed around this. Next the scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the vas ends were pulled together by tying the sutures. A good reapproximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed. [/TRANSCRIPTION] [TASK_OUTPUT] Bilateral vasovasostomy surgery sample. [/TASK_OUTPUT] [DESCRIPTION] Bilateral vasovasostomy surgery sample. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion.

A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

SOAP / Chart / Progress Notes

Recheck of ADHD Meds

soap / chart / progress notes, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,

he, the, his, in, has

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES PERFORMED:,1. Lateral escharotomy of right upper arm burn eschar.,2. Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:, Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:, After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure.

Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.

Surgery

Escharotomy

surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns

upper, the, right, and, was

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES PERFORMED:,1. Lateral escharotomy of right upper arm burn eschar.,2. Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:, Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:, After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar. [/DESCRIPTION] </s>

Extract key medical terms from this text

upper, the, chest, are, right

EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.

CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.

Radiology

CT of Chest with Contrast

radiology, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest

upper, the, chest, are, right

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia. [/TRANSCRIPTION] [TASK_OUTPUT] upper, the, chest, are, right [/TASK_OUTPUT] [DESCRIPTION] CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PRINCIPAL DIAGNOSIS:, Mesothelioma.,SECONDARY DIAGNOSES:, Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. On August 20, 2007, thoracentesis.,3. On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1. Pericardectomy.,2. Pericarditis.,2. Atrial fibrillation.,4. RNCA with intracranial thrombolytic treatment.,5

Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.

Discharge Summary

Discharge Summary - Mesothelioma - 1

chest, history, and, with, right

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PRINCIPAL DIAGNOSIS:, Mesothelioma.,SECONDARY DIAGNOSES:, Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. On August 20, 2007, thoracentesis.,3. On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1. Pericardectomy.,2. Pericarditis.,2. Atrial fibrillation.,4. RNCA with intracranial thrombolytic treatment.,5 [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis. [/DESCRIPTION] </s>

Extract key medical terms from this text

the, right, is, he, has

CHIEF COMPLAINT:, Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:, This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea.,PHYSICAL EXAM:,General: He is alert in no distress.,Vital Signs: Temperature: 99.1 degrees.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,ASSESSMENT:,1. Right otitis media.,2. Right otorrhea.,PLAN:, Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup.

Right ear pain with drainage - otitis media and otorrhea.

Consult - History and Phy.

Ear Pain - Drainage

consult - history and phy., drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,

the, right, is, he, has

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT:, Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:, This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea.,PHYSICAL EXAM:,General: He is alert in no distress.,Vital Signs: Temperature: 99.1 degrees.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,ASSESSMENT:,1. Right otitis media.,2. Right otorrhea.,PLAN:, Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup. [/TRANSCRIPTION] [TASK_OUTPUT] the, right, is, he, has [/TASK_OUTPUT] [DESCRIPTION] Right ear pain with drainage - otitis media and otorrhea. [/DESCRIPTION] </s>

Suggest potential follow-up questions based on this transcription

Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions]

PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

Orthopedic

Neuroplasty

orthopedic, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,

the, left, and, of, with

<s>[INSTRUCTION] Suggest potential follow-up questions based on this transcription [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition. [/TRANSCRIPTION] [TASK_OUTPUT] Based on the transcription, potential follow-up questions could include: [Generate 2-3 relevant questions] [/TASK_OUTPUT] [DESCRIPTION] Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. [/DESCRIPTION] </s>

Extract key medical terms from this text

will, up, is, we, her

SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.

Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.

General Medicine

Gen Med SOAP - 2

general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery

will, up, is, we, her

<s>[INSTRUCTION] Extract key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed. [/TRANSCRIPTION] [TASK_OUTPUT] will, up, is, we, her [/TASK_OUTPUT] [DESCRIPTION] Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc. [/DESCRIPTION] </s>

Generate an appropriate sample name for this transcription

Intensity-Modulated Radiation Therapy

INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.

Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.

Radiology

Intensity-Modulated Radiation Therapy

radiology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

the, are, is, performed, in

<s>[INSTRUCTION] Generate an appropriate sample name for this transcription [/INSTRUCTION] [TRANSCRIPTION] INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate. [/TRANSCRIPTION] [TASK_OUTPUT] Intensity-Modulated Radiation Therapy [/TASK_OUTPUT] [DESCRIPTION] Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. [/DESCRIPTION] </s>

Summarize this medical transcription

Nausea, vomiting, diarrhea, and fever.

CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS: ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full.,NECK: Supple with full range of motion and no masses.,LUNGS: There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN: Soft and nontender with no hepatosplenomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole.,3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium.,4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. ,

Nausea, vomiting, diarrhea, and fever.

General Medicine

Gen Med Consult - 27

the, and, she, is, of

<s>[INSTRUCTION] Summarize this medical transcription [/INSTRUCTION] [TRANSCRIPTION] CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS: ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full.,NECK: Supple with full range of motion and no masses.,LUNGS: There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN: Soft and nontender with no hepatosplenomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole.,3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium.,4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. , [/TRANSCRIPTION] [TASK_OUTPUT] Nausea, vomiting, diarrhea, and fever. [/TASK_OUTPUT] [DESCRIPTION] Nausea, vomiting, diarrhea, and fever. [/DESCRIPTION] </s>

Extract original key medical terms from this text

surgery, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,

PREOPERATIVE DIAGNOSIS: ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section. The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner. A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia. Bleeding points were snapped and coagulated along the way. The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles. These were divided in the midline revealing the peritoneum, which was opened vertically. The uterus was in mid position. The bladder flap was incised elliptically and reflected caudad. A low transverse hysterotomy incision was then constructed and extended bluntly. Amniotomy revealed clear amniotic fluid. A live born vigorous male infant was then delivered from the right occiput transverse position. The infant breathed and cried spontaneously. The nares and pharynx were suctioned. The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team. Cord blood samples were obtained. The placenta was manually removed and the uterus was eventrated for closure. The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first. Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl. The cornual sac and gutters were irrigated. The uterus was returned to the abdominal cavity. The adnexa were inspected and were normal. The abdomen was then closed in layers. Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips. Blood loss was estimated at 700 mL. All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.

Primary low segment cesarean section.

Surgery

Low -Segment C-Section

surgery, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,

the, was, and, were, in

<s>[INSTRUCTION] Extract original key medical terms from this text [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSIS: ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section. The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner. A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia. Bleeding points were snapped and coagulated along the way. The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles. These were divided in the midline revealing the peritoneum, which was opened vertically. The uterus was in mid position. The bladder flap was incised elliptically and reflected caudad. A low transverse hysterotomy incision was then constructed and extended bluntly. Amniotomy revealed clear amniotic fluid. A live born vigorous male infant was then delivered from the right occiput transverse position. The infant breathed and cried spontaneously. The nares and pharynx were suctioned. The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team. Cord blood samples were obtained. The placenta was manually removed and the uterus was eventrated for closure. The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first. Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl. The cornual sac and gutters were irrigated. The uterus was returned to the abdominal cavity. The adnexa were inspected and were normal. The abdomen was then closed in layers. Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips. Blood loss was estimated at 700 mL. All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition. [/TRANSCRIPTION] [TASK_OUTPUT] surgery, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture, [/TASK_OUTPUT] [DESCRIPTION] Primary low segment cesarean section. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals: Weight was 130 pounds and blood pressure 124/78.,HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.,Neck: Supple without adenopathy.,Lungs: Clear.,ASSESSMENT:, Allergic rhinitis.,PLAN:,1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.,2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well.

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

Allergy / Immunology

Allergic Rhinitis

allergy / immunology, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,

she, does, used, has, but

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals: Weight was 130 pounds and blood pressure 124/78.,HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.,Neck: Supple without adenopathy.,Lungs: Clear.,ASSESSMENT:, Allergic rhinitis.,PLAN:,1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.,2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] A 23-year-old white female presents with complaint of allergies. [/DESCRIPTION] </s>

Determine if this transcription is longer or shorter than average

Shorter than average

PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.

Left forearm arteriovenous fistula between cephalic vein and radial artery.

Nephrology

AV Fistula - 5

nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic

the, was, and, artery, he

<s>[INSTRUCTION] Determine if this transcription is longer or shorter than average [/INSTRUCTION] [TRANSCRIPTION] PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied. [/TRANSCRIPTION] [TASK_OUTPUT] Shorter than average [/TASK_OUTPUT] [DESCRIPTION] Left forearm arteriovenous fistula between cephalic vein and radial artery. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.50

HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well. The patient does note that she has been having hearing loss. This is particular prominent in the right ear now for the past three to four years. She does note popping after blowing the nose. Occasionally, the hearing will improve and then it plugs back up again. She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her. She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement. She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage. She feels that she is having a hard time swallowing at times as well. She has complained of a lump sensation in the throat that tends to come and go. She denies any cough, no hemoptysis, no weight change. No night sweats, fever or chills has been noted. She is having at this time no complaints of tinnitus or vertigo. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: ,ALLERGY/IMMUNOLOGIC: History of seasonal allergies. She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR: Pertinent for hypercholesterolemia.,PULMONARY: She has a history of cough, wheezing.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: She has had a history of TIAs in the past.,VISUAL: She does have history of vision change, wears glasses.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: History of joint pain and bursitis.,CONSTITUTIONAL: She has a history of chronic fatigue.,ENT: She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC: History of anxiety, depression.,HEMATOLOGIC: Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984. She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension. Brother, colon CA. Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily. She takes vitamins one a day. She is on Zocor, Desyrel, Flonase, and Xanax. She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling. She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single. She is unemployed at this time. She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL: The patient is an alert, cooperative, well-developed 51-year-old female. She has a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Right ear, the external ear is normal. The ear canal is clean and dry. The drum is intact. She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss. Left ear, the external ear is normal. The ear canal is clean and dry. The drum is intact and mobile with grossly normal hearing. The audiogram does reveal normal hearing in the left ear. She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally. Tympanograms, there was no adequate seal obtained on the right side. She has a normal type A tympanogram, left side.,NASAL: Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms. Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted. The nasopharynx does reveal moderate adenoid pad within this midline. It is nonulcerated. The larynx revealed both cords to be normal. She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION: ,1. Persistent dysphagia. I think secondary most likely to the persistent postnasal drainage.,2. Deviated nasal septum.,3. Inferior turbinate hypertrophy.,4. Chronic rhinitis.,5. Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.

Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.

Consult - History and Phy.

ENT Consult

she, the, normal, and, has

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well. The patient does note that she has been having hearing loss. This is particular prominent in the right ear now for the past three to four years. She does note popping after blowing the nose. Occasionally, the hearing will improve and then it plugs back up again. She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her. She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement. She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage. She feels that she is having a hard time swallowing at times as well. She has complained of a lump sensation in the throat that tends to come and go. She denies any cough, no hemoptysis, no weight change. No night sweats, fever or chills has been noted. She is having at this time no complaints of tinnitus or vertigo. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: ,ALLERGY/IMMUNOLOGIC: History of seasonal allergies. She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR: Pertinent for hypercholesterolemia.,PULMONARY: She has a history of cough, wheezing.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: She has had a history of TIAs in the past.,VISUAL: She does have history of vision change, wears glasses.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: History of joint pain and bursitis.,CONSTITUTIONAL: She has a history of chronic fatigue.,ENT: She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC: History of anxiety, depression.,HEMATOLOGIC: Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984. She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension. Brother, colon CA. Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily. She takes vitamins one a day. She is on Zocor, Desyrel, Flonase, and Xanax. She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling. She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single. She is unemployed at this time. She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL: The patient is an alert, cooperative, well-developed 51-year-old female. She has a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Right ear, the external ear is normal. The ear canal is clean and dry. The drum is intact. She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss. Left ear, the external ear is normal. The ear canal is clean and dry. The drum is intact and mobile with grossly normal hearing. The audiogram does reveal normal hearing in the left ear. She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally. Tympanograms, there was no adequate seal obtained on the right side. She has a normal type A tympanogram, left side.,NASAL: Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms. Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted. The nasopharynx does reveal moderate adenoid pad within this midline. It is nonulcerated. The larynx revealed both cords to be normal. She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION: ,1. Persistent dysphagia. I think secondary most likely to the persistent postnasal drainage.,2. Deviated nasal septum.,3. Inferior turbinate hypertrophy.,4. Chronic rhinitis.,5. Conductive hearing loss, right ear with a history of cholesteatoma of the right ear. [/TRANSCRIPTION] [TASK_OUTPUT] 0.50 [/TASK_OUTPUT] [DESCRIPTION] Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis. [/DESCRIPTION] </s>

Assess the complexity of this medical transcription on a scale of 0 to 1

0.70

CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.

A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye."

Neurology

Lobar Holoprosencephaly

neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine,

he, and, his, at, normal

<s>[INSTRUCTION] Assess the complexity of this medical transcription on a scale of 0 to 1 [/INSTRUCTION] [TRANSCRIPTION] CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable. [/TRANSCRIPTION] [TASK_OUTPUT] 0.70 [/TASK_OUTPUT] [DESCRIPTION] A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye." [/DESCRIPTION] </s>