Datasets:

bhargavi909

/

Medical_Transcriptions_upsampled

like 2

Pediatric Gastroenterology - History of gagging.

Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.

4-day-old with hyperbilirubinemia and heart murmur.

Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.

Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.

Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

Upper endoscopy with removal of food impaction.

The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.

Quick note on tachypnea.

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

Patient scheduled for laparoscopic gastric bypass.

Vaginal discharge with a foul odor.

Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.

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

A sample note on Rheumatoid Arthritis

Microsuspension direct laryngoscopy with biopsy. Fullness in right base of the tongue and chronic right ear otalgia.

Migraine headache - The client was seen in the urgent care.

Modified radical mastectomy. An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further.

Patient presents for care of suspected rheumatoid arthritis.

Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.

Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.

Tonsillectomy. Chronic tonsillitis.

A female for a complete physical and follow up on asthma with allergic rhinitis.

Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

The case was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.

Repeat cesarean section and bilateral tubal ligation.

Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.

Ultrasound - a 22-year-old pregnant female.

Evaluation for bariatric surgery.

Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.

Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.

Patient with atrial fibrillation with slow ventricular response, partially due to medications.

Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.

Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.

Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..

Complex regional discomfort syndrome, right upper extremity. Stellate ganglion block.

Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.

Dietary consultation for diabetes during pregnancy.

A female for a complete physical and follow up on asthma with allergic rhinitis.

Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.

Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.

Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.

An example of a physical exam

Dietary consultation for diabetes during pregnancy.

Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.

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

The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.

Phacoemulsification of cataract, extraocular lens implant in left eye.

A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

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

Repair of upper lid canalicular laceration - Sample/Template.

Bilateral rectus recession with the microscopic control, 8 mm, both eyes.

Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.

Is it BNP or BMP?

Common description of EGD.

Difficulty with both distance vision and with fine print at near.

Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.

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

First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

Specimen labeled "sesamoid bone left foot".

Lumbar epidural steroid injection for lumbar radiculopathy.

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

Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.

Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

Counting calorie points, exercising pretty regularly, seems to be doing well

Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The client is a 78-year-old female with back pain referring into the left side.

Consult and Spinal fluid evaluation in a 15-day-old

Orchiopexy & inguinal herniorrhaphy.

Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.

Patient status post lap band placement.

Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.

Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.

Unilateral transpedicular T11 vertebroplasty.

This client was seen in clinic for a school physical.

Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.

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

Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.

Work restrictions and disability evaluation

The case is 14 months old, comes in with a chief complaint of difficulty breathing.

Fractional dilatation and curettage

Autopsy - Homicide - Blunt force cranial trauma

Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.

A sample note on Rheumatoid Arthritis

A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.

Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.

EGD with dilation for dysphagia.

MRI report Cervical Spine (Chiropractic Specific)

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

Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.

He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.

Elevated cholesterol and is on medication to lower it.

Sample/template for a normal female multisystem exam

A female for a complete physical and follow up on asthma with allergic rhinitis.

Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.

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

A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.

The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.

The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome