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12,622
Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.
17
10,532
Occupational medicine consult with questions-answers and records review.
18
4,861
Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.
10
225
H&P for a female with Angina pectoris.
3
6,187
Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.
16
4,138
The client is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.
12
10,286
Occupational medicine consult with questions-answers and records review.
18
8,796
Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.
18
4,847
Excision of penile skin bridges about 2 cm in size.
39
11,053
A sample note on Rheumatoid Arthritis
34
4,257
The case is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.
24
9,137
Autopsy of a white female who died of acute combined drug intoxication.
1
12,623
Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.
34
6,728
L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.
28
6,648
Newborn circumcision. The penile foreskin was removed using Gomco.
29
1,874
Ultrasound examination of the scrotum due to scrotal pain. Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.
39
4,811
Injection of Morton's neuroma.
28
3,794
Autopsy - Asphyxia due to ligature strangulation.
1
1,569
This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.
36
11,321
Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.
1
4,100
Bilateral temporal artery biopsy. Rule out temporal arteritis.
22
3,343
Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
38
8,830
Chiropractic IME with old files review. Detailed Thoracic Spine Examination.
18
2,326
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
38
8,945
Consultation for left foot pain.
4
3,789
Total abdominal hysterectomy.. Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.
38
5,844
A female for a complete physical and follow up on asthma with allergic rhinitis.
0
4,121
Closure of gastrostomy placed due to feeding difficulties.
14
5,694
2-month-old female - increased work of breathing.
12
8,981
A female for a complete physical and follow up on asthma with allergic rhinitis.
0
4,673
Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.
21
8,619
Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,
6
11,657
Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.
1
11,106
Patient presents for therapy of suspected rheumatoid arthritis.
34
4,026
Laparoscopic tubal sterilization, tubal coagulation.
24
9,070
Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7
2
8,853
History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no ache that radiates from her back into her legs. She has had no associated weakness.
30
8,872
Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.
19
8,891
The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.
37
9,920
Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.
17
8,393
Work restrictions and disability evaluation
4
2,174
Bronchoscopy. Atelectasis and mucous plugging.
3
5,163
Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.
8
4,017
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.
7
5,363
Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.
24
530
Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.
28
1,143
Follow up consultation, second opinion, foreskin.
35
11,433
Patient discharged after laparoscopic Roux-en-Y gastric bypass.
2
4,809
MRI C-spine: C4-5 Transverse Myelitis.
22
9,746
Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.
34
9,080
Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.
19
633
Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.
38
1,418
Patient with worsening shortness of breath and cough.
15
4,205
Left forearm arteriovenous fistula between cephalic vein and radial artery.
21
5,198
Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.
26
472
AP abdomen and ultrasound of kidney.
21
6,463
Nephrology Consultation - Patient with renal failure.
21
2,028
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.
38
356
Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.
22
3,101
Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.
38
9,771
A lady with symptoms consistent with possible oligoarticular arthritis of her knees.
34
5,109
School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.
32
6,598
Discharge summary of a case with mood swings and oppositional and defiant behavior.
32
3,729
Patient being referred for evaluation of glaucoma.
20
9,300
Autopsy - Asphyxia due to ligature strangulation.
1
7,117
The case presents for evaluation at the request of his primary physician for treatment for dystrophic nails.
31
2,575
Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.
38
3,913
Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.
27
3,829
CT abdomen without contrast and pelvis without contrast, reconstruction.
33
8,669
Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.
2
2,357
Sample for Neuropsychological Evaluation
22
8,466
Occupational medicine consult with questions-answers and records review.
18
7,111
Autopsy - Asphyxia due to ligature strangulation.
1
2,513
Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.
6
9,268
Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.
0
12,053
Preop evaluation regarding gastric bypass surgery.
2
6,016
Fever, otitis media, and possible sepsis.
11
7,349
Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome
9
6,817
Coccygeal injection
28
4,462
Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to clinical therapy, severe anemia, and symptomatic fibroid uterus.
10
2,070
A sample note on Angina.
3
6,072
The patient's main complaint is vertigo. The client is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.
11
4,613
This is a 14-month-old baby boy Caucasian who came in with presumptive determination of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.
10
9,315
The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.
37
6,142
Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.
21
8,129
Punch biopsy of right upper chest skin lesion.
8
2,307
The patient is status post C3-C4 anterior cervical discectomy and fusion.
30
11,731
Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.
19
577
Injection of Morton's neuroma.
28
12,209
Is it BNP or BMP?
19
3,132
History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.
15
12,494
Counting calorie points, exercising pretty regularly, seems to be doing well
9
5,463
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.
24
3,299
A male patient presented for evaluation of chronic abdominal pain.
15
10,917
Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.
0
8,346
Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.
7
2,273
A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.
10
3,235
MRI right knee without gadolinium
33
8,315
Patient being referred for evaluation of glaucoma.
20
4,986
Consultation for ICU management for a client with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.
12