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6,220 | Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. | 28 |
3,507 | Patient with several medical problems - numbness, tingling, and a pain in the toes. | 15 |
8,919 | Specimen labeled "sesamoid bone left foot". | 19 |
3,452 | Patient with a 1-year history of progressive anterograde amnesia | 5 |
1,376 | Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia. | 3 |
1,392 | Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy. | 38 |
8,113 | Patient discharged after laparoscopic Roux-en-Y gastric bypass. | 2 |
8,765 | EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. | 36 |
4,216 | 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. | 15 |
482 | Patient with a long history of depression and attention deficits. | 32 |
10,921 | Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma. | 0 |
4,503 | Arthroplasty of the right second digit. Hammertoe deformity of the right second digit. | 31 |
6,703 | Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis. | 11 |
8,781 | Dietary consultation for gestational diabetes. | 9 |
398 | Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. | 3 |
1,945 | Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst. | 16 |
4,810 | Injection of Morton's neuroma. | 28 |
1,732 | Laparoscopic appendectomy. Acute appendicitis. | 14 |
10,660 | Work restrictions and disability evaluation | 18 |
1,702 | Right upper lung lobectomy. Mediastinal lymph node dissection | 38 |
12,520 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
11,390 | Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left. | 13 |
11,986 | Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc. | 4 |
581 | This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade. | 33 |
5,526 | Well-child check sports physical - Well child asthma with good control, allergic rhinitis. | 29 |
12,081 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | 9 |
10,640 | First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. | 18 |
566 | Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture. | 38 |
2,692 | Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity. | 3 |
8,887 | 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 |
1,238 | New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation. | 5 |
10,130 | Patient referred for narrow angles and possible associated glaucoma. | 20 |
836 | Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy. | 38 |
278 | Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea. | 5 |
12,079 | Cause of death - Anoxic Encephalopathy | 1 |
10,296 | Patient discharged after laparoscopic Roux-en-Y gastric bypass. | 2 |
10,122 | Bilateral transaxillary subpectoral mammoplasty with saline-filled implants. | 6 |
11,885 | Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. | 7 |
4,496 | Right distal ureteral calculus. The client had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. | 39 |
942 | Inguinal hernia hydrocele repair. | 38 |
6,301 | 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. | 13 |
3,946 | Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. | 16 |
12,596 | Mother states he has been wheezing and coughing. | 0 |
12,557 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | 17 |
9,667 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | 17 |
3,217 | 2-month-old female - increased work of breathing. | 3 |
4,730 | A sample note on Cataract | 26 |
10,468 | Work restrictions and disability evaluation | 4 |
4,955 | Vitrectomy under local anesthesia. | 26 |
7,483 | 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 |
341 | Sample normal ear, nose, mouth, and throat exam. | 5 |
4,401 | The client is admitted with a diagnosis of acute on chronic renal insufficiency. | 21 |
3,068 | Phacoemulsification with posterior chamber intraocular lens insertion. | 26 |
2,299 | 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. | 24 |
1,991 | Intercostal block, left. Severe post thoracotomy pain. | 28 |
280 | Followup circumcision. The patient had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications. | 39 |
5,514 | An example/template for a routine normal male ROS. | 25 |
5,325 | Cystoscopy. Transurethral resection of the prostate. | 39 |
2,490 | A 10 years of age carries a diagnosis of cystic fibrosis | 5 |
2,583 | Patient today with ongoing issues with diabetic control. | 13 |
5,670 | The case had hematuria, and unable to void. The case had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. | 39 |
9,944 | Occupational medicine consult with questions-answers and records review. | 18 |
12,067 | Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. | 37 |
5,334 | Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm. | 12 |
1,742 | Adenotonsillectomy. Adenotonsillitis with hypertrophy. The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated. | 38 |
1,895 | Common CT Chest template | 33 |
789 | Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess. | 14 |
1,267 | Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin. | 35 |
2,135 | Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. | 38 |
5,115 | Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke. | 32 |
1,616 | Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots. | 27 |
11,314 | Dietary consultation for diabetes during pregnancy. | 9 |
9,798 | Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. | 0 |
1,432 | Patient with right ankle pain. | 27 |
1,524 | Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions. | 38 |
5,448 | A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. | 16 |
3,253 | Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged. | 24 |
10,861 | Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. | 0 |
7,711 | Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain. | 4 |
1,819 | Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. | 14 |
3,641 | Inguinal hernia hydrocele repair. | 39 |
6,069 | Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy. | 10 |
1,106 | This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years. | 33 |
10,507 | Status post brain tumor removal. The client is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. | 30 |
1,793 | General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, | 35 |
10,491 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
10,622 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | 17 |
1,323 | The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints. | 27 |
7,862 | EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. | 36 |
8,106 | Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping. | 6 |
3,880 | Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | 33 |
1,307 | Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain. | 3 |
9,737 | 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 |
9,575 | Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs. | 17 |
5,800 | Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy | 6 |
2,774 | Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction. | 33 |
12,320 | Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. | 17 |
9,837 | Hospice visit for 77-year-old gentleman with advanced colon cancer. | 17 |
6,665 | Belly button piercing for insertion of belly button ring. | 6 |
11,524 | Qualified medical evaluation report of a client with back pain. | 4 |