| Unnamed: 0,description,medical_specialty |
| 4974,,24 |
| 9594,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 4052,,31 |
| 12246,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 2264,,38 |
| 556, Pain management for post-laminectomy low back syndrome and radiculopathy. ,4 |
| 8806,,4 |
| 3034, Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.,38 |
| 7722,Most commonly used phrases in physical exam.,25 |
| 1091, Occupational medicine consult with questions-answers and records review.,18 |
| 5091,,11 |
| 1263, CT chest with contrast.,3 |
| 2344, A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,15 |
| 4445,Followup circumcision. The client had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 |
| 8597,,30 |
| 6244,,13 |
| 3831,,38 |
| 2847, Evaluation and recommendations regarding facial rhytids.,35 |
| 2409, Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 |
| 2106, She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,12 |
| 11906,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 10732,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 |
| 11822,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 10527,,0 |
| 5790,Consultation for left foot pain.,4 |
| 6776,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 |
| 12356,Status post brain tumor removal. The case 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 |
| 4892,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,35 |
| 10979,,0 |
| 4964,,6 |
| 8280,,20 |
| 3319, Left endoscopic carpal tunnel release and endotracheal fasciotomy.,27 |
| 8427,Status post brain tumor removal. The case 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 |
| 9815,,37 |
| 985,,27 |
| 7377,,30 |
| 6420,An example normal physical exam,25 |
| 11942,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 7462,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 8432,Status post brain tumor removal. The case 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 |
| 3094, The patient is being referred for evaluation of diabetic retinopathy.,26 |
| 3596, MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.,22 |
| 1670,,5 |
| 7440,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 1360, Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 |
| 10764,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 11515,,37 |
| 4236,Decreased ability to perform daily living activities secondary to right knee surgery.,10 |
| 7290,,17 |
| 4860,,10 |
| 9768,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 10656,A 23-year-old white female presents with complaint of allergies.,0 |
| 6551,,16 |
| 12042,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 5636,Patient had a markedly abnormal stress test with severe chest ache after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,25 |
| 6995,,31 |
| 1919, Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. ,38 |
| 3755,,13 |
| 11100,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 2880,,15 |
| 1503,,39 |
| 12244,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 10465,,18 |
| 1875, Flexible sigmoidoscopy due to rectal bleeding.,14 |
| 420, Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,5 |
| 5674,,13 |
| 8631,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 5847,,11 |
| 11219,,30 |
| 8193,,8 |
| 1625,,35 |
| 404, Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,38 |
| 7865,,36 |
| 3251,,2 |
| 9918,,9 |
| 2109,,38 |
| 8923,,19 |
| 8546,,30 |
| 7121,Caudal epidural steroid injection without fluoroscopy.,28 |
| 6867,,11 |
| 11587,,1 |
| 2177, Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,22 |
| 8022,A 21-channel digital electroencephalogram was performed on a case in the awake state.,36 |
| 10484,,17 |
| 521, Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.,38 |
| 1856,,14 |
| 10236,,19 |
| 8292,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 |
| 230,,3 |
| 8480,,4 |
| 7099,,13 |
| 2566, The patient was exercised according to standard Bruce protocol for 9 minutes.,3 |
| 7963,,6 |
| 8668,,2 |
| 369, The patient with a recent change in bowel function and hematochezia.,14 |
| 7310,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 10148,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 |
| 753, Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,35 |
| 5698,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.,16 |
| 6412,Intensity-modulated radiation therapy simulation note. The client will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.,16 |
| 10508,Status post brain tumor removal. The case 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 |
| 11864,,34 |
| 4371,Most commonly used phrases in physical exam.,25 |
| 8021,A 21-channel digital electroencephalogram was performed on a client in the awake state.,36 |
| 8790,Is it BNP or BMP?,19 |
| 6791,,11 |
| 5406,,29 |
| 10169,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 6135,A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The case was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,12 |
| 3482, Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,27 |
| 8132,,8 |
| 10983,,1 |
| 962,,39 |
| 11755,,0 |
| 4402,The patient is admitted with a determination of acute on chronic renal insufficiency.,21 |
| 1235, Bilateral vasovasostomy surgery sample.,39 |
| 2967, Acromioclavicular joint injection,28 |
| 11844,A sample note on Rheumatoid Arthritis,34 |
| 2327,,38 |
| 11050,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 4987,Consultation for ICU management for a client with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 |
| 1127,,22 |
| 10724,,19 |
| 2934, Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 |
| 12160,,1 |
| 5187,,24 |
| 1031, Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 |
| 151, Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. ,14 |
| 1105, Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,3 |
| 1024, Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,27 |
| 8436,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 4222,,39 |
| 3148,,15 |
| 611,,33 |
| 2728, CT Abdomen & Pelvis W&WO Contrast,14 |
| 2798,,10 |
| 3777, CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.,27 |
| 5263,,11 |
| 3779, Concomitant chemoradiotherapy for curative intent patients.,16 |
| 3765, NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.,38 |
| 12427,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 |
| 6573,Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,23 |
| 4585,"Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.",35 |
| 10656,A 23-year-old white female presents with complaint of allergies.,0 |
| 10470,Work restrictions and disability evaluation,4 |
| 7590,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 2621," Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.",38 |
| 7731,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 |
| 8135,Consult for laparoscopic gastric bypass.,2 |
| 4360,"Open reduction, nasal fracture with nasal septoplasty.",11 |
| 6322,Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.,11 |
| 12503,"Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. |
| |
| |
| |
| A 54-year-old patient, here for evaluation of new-onset swelling of the tongue. |
| Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate. |
| Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. |
| Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. |
| Multiple contusions and abdominal pain, status post motor vehicle collision. |
| The case died of a pulmonary embolism, the underlying cause of which is currently undetermined. |
| Specimen labeled sesamoid bone left foot. |
| |
| |
| |
| |
| |
| Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation. |
| |
| |
| Patient suffers from neck and lower back discomfort radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms. |
| |
| |
| |
| The client died of a pulmonary embolism, the underlying cause of which is currently undetermined. |
| |
| Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry. |
| |
| |
| Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy. |
| |
| Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp. |
| Status post brain tumor with removal. The case 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. |
| |
| Followup diabetes mellitus, type 1. |
| Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. |
| |
| |
| |
| Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct. |
| |
| Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending. |
| |
| |
| |
| |
| Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye. |
| |
| |
| |
| CT abdomen and pelvis without contrast, stone protocol, reconstruction. |
| Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension. |
| |
| Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 |
| 3638," Irritable baby, 6-week-old, with fever for approximately 24 hours.",29 |
| 1214," DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,",3 |
| 12069,"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 |
| 1909, Patient comes for discussion of a screening colonoscopy. ,5 |
| 3863," Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm. |
| |
| A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. |
| Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain. |
| |
| |
| |
| |
| |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 4456,"Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past clinical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.",22 |
| 10523,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 11503,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 |
| 3226, CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,33 |
| 4419,A 61-year-old white male with a identification of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,35 |
| 12077,Cause of death - Anoxic Encephalopathy,1 |
| 10327,"Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.",13 |
| 1726," Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.",3 |
| 1689, Total colonoscopy and polypectomy,14 |
| 10535,Occupational medicine consult with questions-answers and records review.,18 |
| 6718,Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 |
| 4307,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 6871,"Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.",26 |
| 4545,"She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The case has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The case is starting to improve, gain more strength. She is tolerating her regular diet.",14 |
| 688, Complaint of mood swings and tearfulness.,15 |
| 8691,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 2065, MRI left knee without contrast.,33 |
| 984," 5-month recheck on type II diabetes mellitus, as well as hypertension.",15 |
| 5787,"Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 |
| 626, 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. ,5 |
| 11658,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 339, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,38 |
| 3138, MRI right ankle.,31 |
| 6548,Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 |
| 9827,"The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 |
| 5969,Ophthalmology followup visit note.,26 |
| 5931,Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.,32 |
| 7418,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 |
| 4193,"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.",21 |
| 2911, Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,3 |
| 8681,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 |
| 4521,Recurrent bladder tumor. The client on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,39 |
| 11857,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 |
| 885," Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.",27 |
| 2564," Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 |
| 12430,"Specimen labeled ""sesamoid bone left foot"".",19 |
| 3742, Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success. ,2 |
| 1710," Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. ",22 |
| 11623,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and Right upper lobe lung. |
| The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 11618,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and Right upper lobe lung. |
| |
| Counting calorie points, exercising pretty regularly, seems to be doing well |
| |
| Specimen labeled right ovarian cyst is received fresh for frozen section. |
| Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System. |
| |
| |
| Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed. |
| Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. |
| |
| |
| |
| |
| Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis. |
| Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. |
| 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. |
| |
| |
| |
| Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure. |
| Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain. |
| Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. |
| A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. |
| Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome. |
| |
| |
| |
| Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease. |
| Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study. |
| |
| Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.",31 |
| 12450,Speech therapy discharge summary. The case was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 1017, Dietary consultation for gestational diabetes.,9 |
| 9155,Occupational medicine consult with questions-answers and records review.,18 |
| 7929,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 |
| 12192,,19 |
| 1998,,5 |
| 6039,Generalized abdominal discomfort with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,21 |
| 4340,,14 |
| 3486, Right nodular malignant mesothelioma.,16 |
| 5350,,31 |
| 5464,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,24 |
| 8567,,20 |
| 6604,Tonsillectomy. Chronic tonsillitis.,11 |
| 8511,,30 |
| 7585,Is it BNP or BMP?,19 |
| 2241,,39 |
| 10382,,30 |
| 10538,,4 |
| 4859,Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The client was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.,21 |
| 6380,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 |
| 7317,A sample note on Rheumatoid Arthritis,34 |
| 6081,,10 |
| 583,,5 |
| 2850, HCT: Subdural hemorrhage.,33 |
| 7230,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 8474,,4 |
| 6905,Sample post dilation client instructions.,26 |
| 1297,,5 |
| 379, Ultrasound-Guided Paracentesis for Ascites,33 |
| 183,,16 |
| 12364,Occupational medicine consult with questions-answers and records review.,18 |
| 7367,Occupational medicine consult with questions-answers and records review.,18 |
| 7726,,7 |
| 11909,Occupational medicine consult with questions-answers and records review.,18 |
| 4769,Polycythemia rubra vera. The case is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months.,16 |
| 10068,,36 |
| 7403,,18 |
| 12272,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 6266,Pain management sample progress note.,28 |
| 4863,,26 |
| 8587,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 38, Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. ,38 |
| 8715,A 23-year-old white female presents with complaint of allergies.,0 |
| 394, Progressive loss of color vision OD.,5 |
| 3639, Left excisional breast biopsy due to atypical ductal hyperplasia of left breast.,38 |
| 4612,,10 |
| 3358, MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,27 |
| 11122,,17 |
| 4708,Spermatocelectomy and orchidopexy,39 |
| 3842,,37 |
| 4961,Lumbar epidural steroid injection for lumbar radiculopathy.,28 |
| 965, Left flank pain and unable to urinate.,5 |
| 6633,The case is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,29 |
| 7763,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 |
| 5932,Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.,32 |
| 7624,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 |
| 4727,,35 |
| 1967, Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.,38 |
| 10602,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 12375,,30 |
| 9976,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 |
| 3301,,22 |
| 10017,Follow up update on client with left carotid angioplasty and stent placement.,20 |
| 11805,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 6732,Phacoemulsification with posterior chamber intraocular lens insertion.,26 |
| 12457,,19 |
| 6918,Incision and drainage of right buccal space abscess and teeth extraction.,7 |
| 3796,,28 |
| 1633,,27 |
| 11788,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 8953,Consultation for left foot pain.,4 |
| 12188,,19 |
| 4751,,35 |
| 10304,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 |
| 2173, Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. ,38 |
| 5468,,23 |
| 3425,,24 |
| 9937,,7 |
| 10118,,19 |
| 970,,39 |
| 8813,Occupational medicine consult with questions-answers and records review.,18 |
| 2694, Punch biopsy of right upper chest skin lesion.,38 |
| 6078,Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,10 |
| 8300,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 |
| 6883,Psychological Testing for ADHD,32 |
| 5016,,35 |
| 6460,Consultation for wrist pain.,4 |
| 3035, Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 |
| 51,,38 |
| 10459,,13 |
| 10743,,19 |
| 6773,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,21 |
| 8984,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 260,,38 |
| 8300,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 |
| 6809,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 |
| 10122,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 |
| 10824,,19 |
| 922,,38 |
| 5924,,12 |
| 3576, Death summary of an 80-year-old patient with a history of COPD.,10 |
| 1834, Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.,38 |
| 2162, The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,3 |
| 12467,,37 |
| 6448,Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal ache for the last 14 days.,12 |
| 614,,38 |
| 9384,,37 |
| 8650,,6 |
| 8200,,7 |
| 2751,,27 |
| 11939,,30 |
| 2361, Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,16 |
| 12365,Occupational medicine consult with questions-answers and records review.,18 |
| 7533,,0 |
| 5098,Urine leaked around the ostomy site for his right sided nephrostomy tube. The case had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,12 |
| 9045,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 605, An example/template for meatotomy.,38 |
| 7228,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 9067,,2 |
| 719,,15 |
| 386,,3 |
| 2221,,33 |
| 8311,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 |
| 12358,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 4169,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 |
| 11445,Consult for laparoscopic gastric bypass.,2 |
| 7985,,8 |
| 7952,,13 |
| 2158, Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,3 |
| 1874, 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 |
| 6607,,21 |
| 11975,Dietary consultation for gestational diabetes.,9 |
| 263, A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,35 |
| 8998,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 8928,,13 |
| 4896,,21 |
| 5511,Discharge summary of a case with depression and high risk behavior.,10 |
| 2358, Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.,5 |
| 4732,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 8115,Completion thyroidectomy with limited right paratracheal node dissection.,13 |
| 12569,,19 |
| 6615,Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 |
| 8438,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 608, Nephrology office visit for followup of microscopic hematuria.,21 |
| 11631,Dietary consultation for gestational diabetes.,9 |
| 11919,,30 |
| 11378,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 1886, A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,16 |
| 9045,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 7931,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 |
| 8262,"Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.",2 |
| 10512,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 9563,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 |
| 6958,"Gangrene osteomyelitis, right second toe. The client is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The client has history of previous right foot infection requiring first ray resection.",31 |
| 5403,"Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",21 |
| 11727,"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 |
| 8967,Mother states he has been wheezing and coughing.,0 |
| 5326,Cystoscopy. Transurethral resection of the prostate.,39 |
| 9391,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 |
| 4895,A sample note on bilateral myringotomy tubes,11 |
| 6041,"Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.",23 |
| 3706," Right shockwave lithotripsy, cystoscopy, and stent removal x2.",21 |
| 10856,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 1653, Normal child physical exam template.,5 |
| 5573,An example/template for a routine normal female physical exam.,25 |
| 181," Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. ",27 |
| 9383,"Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. |
| |
| |
| |
| Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. |
| Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism. |
| |
| |
| |
| The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home. |
| |
| |
| Questionable foreign body, right nose. Belly and back pain. Mild constipation. |
| Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation. |
| |
| |
| |
| |
| |
| A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall. |
| |
| |
| |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 677," Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",16 |
| 12198,Dietary consultation for gestational diabetes.,9 |
| 8513,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 |
| 6931,"Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.",31 |
| 6970,Cervical Selective Nerve Root Block,28 |
| 2930, An example/template for a routine normal male ROS.,5 |
| 12410,Dietary consultation for gestational diabetes.,9 |
| 3379, Bilateral open carpal tunnel release.,38 |
| 11612,A 23-year-old white female presents with complaint of allergies.,0 |
| 5561,A lady was admitted to the hospital with chest discomfort and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.,10 |
| 2973, DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. ,3 |
| 6295,Nephrology office visit for followup of CKD.,21 |
| 3841," Melena and solitary erosion over a fold at the GE junction, gastric side.",14 |
| 4196,Procedure note on Keller Bunionectomy,31 |
| 7915,"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 |
| 3879," There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. ",15 |
| 6737,Patient scheduled for laparoscopic gastric bypass.,2 |
| 2744, Colonoscopy to screen for colon cancer,14 |
| 4628,"Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.",29 |
| 4507,"Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat. |
| |
| |
| |
| Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome |
| Specimen labeled sesamoid bone left foot. |
| |
| Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate. |
| Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor. |
| A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the determination of intracranial bleeding. |
| |
| Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 |
| 5794,"Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.",13 |
| 10898,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 12649,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 4461,"Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to healthcare therapy, severe anemia, and symptomatic fibroid uterus.",10 |
| 9042,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 |
| 1458, Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 |
| 11402,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 |
| 2219," Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210. |
| |
| |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 1377," 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.",38 |
| 1288, A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,16 |
| 12101,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 2716," Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.",38 |
| 5131,"Radical retropubic prostatectomy, robotic assisted and bladder suspension. Adenocarcinoma of the prostate.",39 |
| 7215,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 |
| 8702,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. |
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| |
| |
| Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot. |
| Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions. |
| Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc. |
| Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. |
| |
| |
| Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast. |
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| Right open carpal tunnel release and cortisone injection, left carpal tunnel. |
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| Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached. |
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| Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32. |
| Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis. |
| |
| Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. |
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| Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing. |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 10857,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 8073,Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,20 |
| 4989,"The case was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 |
| 9853,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and Right upper lobe lung. |
| Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria. |
| The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. |
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| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 12264,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 3408," 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.",5 |
| 12447,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 |
| 11098,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 8516,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 |
| 3637," Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.",38 |
| 3340," Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.",22 |
| 6784,MRI right ankle.,31 |
| 1631, Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%,3 |
| 6631,"Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.",23 |
| 10059,Evaluation for bariatric surgery.,2 |
| 11398,"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 |
| 5459,Bilateral vasovasostomy surgery sample.,39 |
| 201, Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. ,38 |
| 2914, Patient with complaint of symptomatic cholelithiasis.,14 |
| 9676,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 11103,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 5677,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 |
| 4735,"Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.",10 |
| 12328,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 6998,The case needs refills on her Xanax,25 |
| 7758,Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.,8 |
| 6920,"Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming determination of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.",12 |
| 4791,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 8264,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 |
| 10159,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 |
| 3108, Complaint of left otalgia (serous otitis) and headache. History of atopic dermatitis.,15 |
| 8424,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 3332, Procedure note on Keller Bunionectomy,38 |
| 1798," Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.",33 |
| 795," Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain. ",35 |
| 6028,"Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.",12 |
| 5384,"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.",36 |
| 12353,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 11310,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 |
| 11018,Is it BNP or BMP?,19 |
| 8530,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 |
| 5311,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 |
| 8519,Chiropractic IME with answers to questions from Insurance Company.,20 |
| 7175,"Intercostal block from fourth to tenth intercostal spaces, left. Chest ache secondary to fractured ribs, unmanageable with narcotics.",28 |
| 9430,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 1808," MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.",22 |
| 9888,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 4377,"Surgical removal of completely bony impacted teeth #1, #16, #17, and #32. Completely bony impacted teeth #1, #16, #17, and #32.",7 |
| 8628,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 2145, Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,3 |
| 3543," The patient is 14 months old, comes in with a chief complaint of difficulty breathing. ",12 |
| 2191," Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.",38 |
| 9560,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 6597,Discharge summary of a client with mood swings and oppositional and defiant behavior.,32 |
| 3889, Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,38 |
| 11044,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 1307, Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,3 |
| 2314, Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. ,5 |
| 713," 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.",38 |
| 4581,Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,32 |
| 1180, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,28 |
| 4909,"Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.",16 |
| 3295, Consultation - an 87-year-old white female with weakness and a history of polymyositis.,5 |
| 157," The patient 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 |
| 6231,"Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.",23 |
| 3654, Common description of EGD.,38 |
| 4035,"Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.",24 |
| 4717,This client has reoccurring ingrown infected toenails.,31 |
| 3105, Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.,22 |
| 7192,Well-child check and school physical.,29 |
| 8190,Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.,6 |
| 28," Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.",24 |
| 11635,Is it BNP or BMP?,19 |
| 6462,Nephrology Consultation - Patient with renal failure.,21 |
| 5548,Marked right hydronephrosis without hydruria.,21 |
| 2633," Psychiatric evaluation for ADHD, combined type.",32 |
| 4854,"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.",23 |
| 6431,"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.",23 |
| 4853,Followup on chronic kidney disease.,21 |
| 3397, Chronic snoring in children,36 |
| 3265," Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port.",3 |
| 7732,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 |
| 1805, Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,24 |
| 3115, Epididymectomy,39 |
| 4353,Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,23 |
| 10237,"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 |
| 708," Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.",27 |
| 1343, Left lower lobectomy.,3 |
| 9682,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 7698,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 9293,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 2354," C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.",27 |
| 7054,Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,12 |
| 8188,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.,6 |
| 11640,Is it BNP or BMP?,19 |
| 5788,"Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.",16 |
| 11865,"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 |
| 3615, Pain and swelling in the right foot.,27 |
| 2379, Acne with folliculitis.,35 |
| 5991,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,28 |
| 3026, Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,32 |
| 8359,Back injury with RLE radicular symptoms. The case is a 52-year-old male who is here for independent medical evaluation.,18 |
| 6662,"Discharge summary of case with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.",16 |
| 6616,Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,23 |
| 8935,"Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.",13 |
| 310, Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,38 |
| 12367,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 |
| 12202,Is it BNP or BMP?,19 |
| 5158,A 3-year-old abrupt onset of cough and increased work of breathing.,29 |
| 10763,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 1784, Template for History and Physical for a newborn.,25 |
| 9908,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 |
| 5151,"Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",12 |
| 1960, Sellar HCT - Pituitary mass,33 |
| 8531,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 |
| 1326, Lower Extremity Arterial Doppler,3 |
| 2310, CT REPORT - Soft Tissue Neck,27 |
| 1632," Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.",38 |
| 9062,"Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7",2 |
| 6093,Standard celiac plexus block procedure note.,28 |
| 11712,A sample note on Rheumatoid Arthritis,34 |
| 4270,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.,15 |
| 3612, Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,22 |
| 1494, Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 |
| 11956,"The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.",36 |
| 3370, Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.,10 |
| 7719,Patient dropped a weight on the dorsal aspects of his feet.,31 |
| 6196,"Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.",11 |
| 6339,Completion thyroidectomy with limited right paratracheal node dissection.,13 |
| 3501, Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,38 |
| 11137,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| |
| Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles. |
| |
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| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 9499,"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 |
| 6547,Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.,21 |
| 8237,"1+ year, black female for initial evaluation of a lifelong history of atopic eczema.",8 |
| 6317,Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 |
| 8321,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 |
| 5532,A female with unknown gestational age who presents to the ED after a suicide attempt.,12 |
| 8969,Mother states he has been wheezing and coughing.,0 |
| 2071, Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,28 |
| 6105,"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 |
| 478, Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.,27 |
| 7596,Mother states he has been wheezing and coughing.,0 |
| 8355,Qualified healthcare evaluation report of a patient with back pain.,4 |
| 11656,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 1107, A female with unknown gestational age who presents to the ED after a suicide attempt.,5 |
| 1517, The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,3 |
| 3616, Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. ,16 |
| 6949,"Onychomycosis present, #1, #2, #3, #4, and #5 right and left.",31 |
| 6157,Preop evaluation regarding gastric bypass surgery.,2 |
| 4672,"Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 |
| 7700,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 183," Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.",16 |
| 1818, Autopsy - Homicide - Blunt force cranial trauma,1 |
| 11908,Occupational medicine consult with questions-answers and records review.,18 |
| 4267,The case comes in today because of feeling lightheaded and difficulty keeping his balance.,22 |
| 8146,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 |
| 8992,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 4262,"The case is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.",32 |
| 424," Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.",27 |
| 4092,"The client is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation. This pregnancy is a twin gestation. The client presents for her fetal anatomical survey.",24 |
| 2726," Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.",38 |
| 1524," Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.",38 |
| 3201, Bilateral breast MRI with & without IV contrast.,24 |
| 3403," Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.",5 |
| 8090,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 12021,Mother states he has been wheezing and coughing.,0 |
| 5657,Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,11 |
| 5630,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 |
| 9473,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 10084,"Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.",18 |
| 2284," Brachytherapy, iodine-125 seed implantation, and cystoscopy.",39 |
| 11499,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 |
| 3048, Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,38 |
| 866, Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,22 |
| 10316,"Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.",2 |
| 9828,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 8400,"Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome",9 |
| 12574,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and Right upper lobe lung. |
| |
| |
| |
| |
| Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer. |
| A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. |
| |
| The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. |
| Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris |
| 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. |
| |
| |
| |
| Excision of nasal tip basal carcinoma, previous positive biopsy. |
| |
| |
| A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever. |
| Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. |
| |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 4765,Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.,39 |
| 9090,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 |
| 4734,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 5534,Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,23 |
| 9157,Occupational medicine consult with questions-answers and records review.,18 |
| 2447, MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,33 |
| 11360,Mother states he has been wheezing and coughing.,0 |
| 5600,Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The client is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.,29 |
| 2518, Colpocleisis and rectocele repair.,38 |
| 995, Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation.,38 |
| 11841,A sample note on Rheumatoid Arthritis,34 |
| 6126,Trabeculectomy with mitomycin C - Sample/Template.,26 |
| 2275, Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot. ,38 |
| 2744, Colonoscopy to screen for colon cancer,14 |
| 6764,"Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",21 |
| 9909,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 |
| 9267,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 5568,"Congestion, tactile temperature.",29 |
| 11014,"Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and Right upper lobe lung. |
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| |
| Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. |
| Ankle sprain, left ankle. The case tripped over her dog toy and fell with her left foot inverted. The case states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the case continued to have significant debilitating ache in her left ankle. She then received a walking boot and has been in the boot for the past month. |
| |
| |
| He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. |
| |
| Patient with a history of PTSD, depression, and substance abuse. |
| MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding. |
| |
| |
| Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. |
| Specimen labeled right ovarian cyst is received fresh for frozen section. |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 4869,"Right inguinal hernia. Right inguinal hernia repair. The client is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.",39 |
| 11406,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 |
| 10113,"Patient suffers from neck and lower back ache radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 |
| 3954, MRI Brain: Subacute right thalamic infarct.,22 |
| 4639,"Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.",24 |
| 7478,Cause of death - Anoxic Encephalopathy,1 |
| 1922, Ophthalmology followup visit note.,26 |
| 6362,Repair of ruptured globe involving posterior sclera - Sample/Template.,26 |
| 2217," Pelvic tumor, cystocele, rectocele, and uterine fibroid. Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus. ",39 |
| 11272,Work restrictions and disability evaluation,18 |
| 11583,"The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.",1 |
| 11055,A sample note on Rheumatoid Arthritis,34 |
| 6666,Sepsis. The case was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,16 |
| 5238,Patient with immune thrombocytopenia,35 |
| 11109,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 7337,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 1660, The patient with continued problems with her headaches. ,25 |
| 10517,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 1866," An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.",12 |
| 11325,"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 |
| 5400,An example of a physical exam,25 |
| 4726,"A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.",35 |
| 11259,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 1254, Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,38 |
| 4674,"Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.",21 |
| 11091,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 5609,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.,12 |
| 1121, Consult for laparoscopic gastric bypass.,5 |
| 7880,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 |
| 7858,"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 |
| 8345,Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 |
| 854," Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.",35 |
| 4309,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 6292,"Adenotonsillectomy, primary, client under age 12.",11 |
| 1122, Cystoscopy. Transurethral resection of the prostate.,38 |
| 8067,"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.",6 |
| 9770,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 763," Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 |
| 9318,"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 |
| 6533,"Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.",6 |
| 3502," Placement of Scott cannula, right lateral ventricle",23 |
| 5307,Is it BNP or BMP?,19 |
| 2118, Patient returns for his first followup after shunt surgery.,22 |
| 2459," Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.",23 |
| 10142,"Followup diabetes mellitus, type 1.",13 |
| 11109,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 9793,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| |
| |
| |
| |
| |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 8308,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 |
| 9997,"Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,",6 |
| 1634," Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.",38 |
| 7912,"Patient suffers from neck and lower back discomfort radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.",20 |
| 6839,"Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the client ended up taking a total of six Ecstasy tablets.",12 |
| 904, Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 |
| 2902," Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.",38 |
| 9221,Cause of death - Anoxic Encephalopathy,1 |
| 8593,"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.",30 |
| 4886,"Incision and drainage, first metatarsal head, left foot with culture and sensitivity.",10 |
| 8241,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 |
| 558," Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.",15 |
| 2380, Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux. ,10 |
| 4957,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 |
| 9110,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 |
| 10734,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 |
| 9252,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 8503,,37 |
| 1508, Left lower extremity venous Doppler ultrasound,33 |
| 4083,,9 |
| 6754,The client is being referred for evaluation of diabetic retinopathy.,26 |
| 10472,Work restrictions and disability evaluation,4 |
| 6226,Consult for laparoscopic gastric bypass.,2 |
| 669, Patient with a history of right upper pons and right cerebral peduncle infarction.,22 |
| 4627,,29 |
| 5168,,39 |
| 5704,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 |
| 5579,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 |
| 7239,Mother states he has been wheezing and coughing.,0 |
| 9554,,34 |
| 4662,,23 |
| 1465, 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.,25 |
| 9274,,0 |
| 2905,,27 |
| 7559,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 9005,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.,13 |
| 9646,,1 |
| 12473,,0 |
| 6650,Newborn circumcision. The penile foreskin was removed using Gomco.,29 |
| 6445,Patient today with ongoing issues with diabetic control.,13 |
| 7550,,1 |
| 5375,Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 |
| 11620,,19 |
| 1038,,21 |
| 1696,,15 |
| 10975,,0 |
| 5445,Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 |
| 3210, MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.,33 |
| 2534, Punch biopsy of right upper chest skin lesion.,8 |
| 5118,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 |
| 9307,,37 |
| 1428, Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.,38 |
| 8470,Occupational medicine consult with questions-answers and records review.,18 |
| 8522,Chiropractic IME with answers to questions from Insurance Company.,20 |
| 11712,A sample note on Rheumatoid Arthritis,34 |
| 2259,,28 |
| 2603,,3 |
| 2436, This is a 95.5-hour continuous video EEG monitoring study.,22 |
| 8028,,9 |
| 7452,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 2172, A 53-year-old female with left knee pain being evaluated for ACL tear.,27 |
| 1401,,21 |
| 169, Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. ,5 |
| 6687,,9 |
| 8331,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 12379,,1 |
| 6586,Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.,8 |
| 7668,Work restrictions and disability evaluation,4 |
| 12463,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 |
| 8816,Occupational medicine consult with questions-answers and records review.,18 |
| 9000,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.,13 |
| 8274,Chronic snoring in children,36 |
| 10611,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 4669,,39 |
| 2058, Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,14 |
| 6077,Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.,10 |
| 9801,,0 |
| 2022,,26 |
| 5046,Cardiology office visit sample note.,25 |
| 11984,,4 |
| 182, Orchiopexy & inguinal herniorrhaphy.,38 |
| 9638,,1 |
| 8689,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 451, A 65-year-old man with chronic prostatitis returns for recheck.,39 |
| 247, The patient is admitted with a diagnosis of acute on chronic renal insufficiency.,21 |
| 8462,,7 |
| 9656,,1 |
| 7545,,1 |
| 7064,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 |
| 1441, A simple note on Acne Vulgaris.,8 |
| 282,,24 |
| 4733,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 3859, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,7 |
| 9916,,9 |
| 8001,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.,8 |
| 9645,,1 |
| 10435,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 3922, Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.,3 |
| 7555,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 3834, Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,27 |
| 9761,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 4178,Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient clinical therapy.,11 |
| 5870,A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.,16 |
| 4002,This is a middle-aged female with two month history of low back discomfort and leg pain.,22 |
| 5108,The case 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.,16 |
| 267, Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 |
| 11257,,36 |
| 11981,,18 |
| 6313,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 2938, Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.,38 |
| 12062,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 1677,,38 |
| 303, Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.,23 |
| 9760,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 8248,,20 |
| 7490,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 11302,Occupational medicine consult with questions-answers and records review.,18 |
| 455,,26 |
| 7587,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 2931,,38 |
| 4583,,29 |
| 8941,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 10631,,2 |
| 7968,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 7017,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.,26 |
| 9881,Mother states he has been wheezing and coughing.,0 |
| 9057,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 |
| 8916,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 |
| 7900,Dietary consultation for diabetes during pregnancy.,9 |
| 3016, Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,23 |
| 6208,Right pleural effusion and suspected malignant mesothelioma.,16 |
| 7999,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 7807,,6 |
| 10139,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 |
| 11020,Is it BNP or BMP?,19 |
| 471, Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,38 |
| 12058,,19 |
| 2463,,10 |
| 5464,A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,24 |
| 9575,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 1131, Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. ,15 |
| 10521,,0 |
| 9171,,37 |
| 5923,Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 |
| 8293,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 |
| 6919,,12 |
| 7926,Patient referred for narrow angles and possible associated glaucoma.,20 |
| 5520,,30 |
| 4023,Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,23 |
| 9055,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 |
| 7303,,1 |
| 3096,,8 |
| 1346, Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.,38 |
| 872,,16 |
| 3987,,26 |
| 1551, A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.,5 |
| 7536,,0 |
| 3101,,38 |
| 10346,Cause of death - Anoxic Encephalopathy,1 |
| 180, Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 6037,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 8241,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 |
| 7612,A sample note on Rheumatoid Arthritis,34 |
| 9056,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 |
| 4258,,24 |
| 2725,,3 |
| 10753,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 11195,,4 |
| 5724,Adenoidectomy procedure,11 |
| 5651,A white female with a history of fevers.,10 |
| 5749,One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.,26 |
| 5791,Consultation for left foot pain.,4 |
| 10752,Mother states he has been wheezing and coughing.,0 |
| 4522,Recurrent bladder tumor. The client on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.,39 |
| 10687,Is it BNP or BMP?,19 |
| 6579,,8 |
| 7990,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 |
| 1770, Phacoemulsification with intraocular lens placement. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. ,26 |
| 2272,,33 |
| 3404, MRI right ankle.,27 |
| 10745,Mother states he has been wheezing and coughing.,0 |
| 3646, Patient presents with gross hematuria that started this morning.,39 |
| 5049,Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.,24 |
| 622,,23 |
| 3400, Caudal epidural steroid injection,28 |
| 7613,A sample note on Rheumatoid Arthritis,34 |
| 10056,Work restrictions and disability evaluation,18 |
| 12167,,1 |
| 4782,The client was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.,35 |
| 1650,,26 |
| 8644,,6 |
| 4619,,12 |
| 2867, Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 |
| 3676,,26 |
| 6062,,23 |
| 1041,,24 |
| 6876,A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,12 |
| 4987,Consultation for ICU management for a client with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 |
| 2606, Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.,38 |
| 5018,,35 |
| 7457,,19 |
| 2084,,5 |
| 2182, Significant pain in left lower jaw.,7 |
| 5676,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 |
| 7765,,20 |
| 9097,Preop evaluation regarding gastric bypass surgery.,2 |
| 3364,,27 |
| 3896,,22 |
| 7919,Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,6 |
| 1397, Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.,35 |
| 8693,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 2007, Laparoscopic right partial nephrectomy due to right renal mass.,38 |
| 4037,,24 |
| 1951,,38 |
| 4212,A 60-year-old female presents today for care of painful calluses and benign lesions.,35 |
| 2405, Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,23 |
| 2549, Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.,39 |
| 178,,12 |
| 8810,,4 |
| 5917,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.,13 |
| 10779,A sample note on Rheumatoid Arthritis,34 |
| 9475,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 3574, Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.,38 |
| 8265,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 |
| 3892, Circumcision and release of ventral chordee.,38 |
| 12367,,4 |
| 10014,,6 |
| 12123,,9 |
| 4808,MRI C-spine: C4-5 Transverse Myelitis.,22 |
| 1486,,38 |
| 4498,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 |
| 4143,,10 |
| 3305,,15 |
| 5356,,39 |
| 250,,15 |
| 12460,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 9164,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 11326,,19 |
| 9920,,17 |
| 7286,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 12573,,19 |
| 11208,,30 |
| 12253,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 4018,,7 |
| 5506,A patient with preoperative identification of right pleural mass and postoperative identification of mesothelioma.,16 |
| 5060,Burr hole and insertion of external ventricular drain catheter.,23 |
| 10234,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 1712, Dietary consultation for carbohydrate counting for type I diabetes.,35 |
| 4013,Direct right inguinal hernia. Marlex repair of right inguinal hernia.,39 |
| 8361,,18 |
| 11718,A sample note on Rheumatoid Arthritis,34 |
| 1069, Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 |
| 10398,Incision and drainage of right buccal space abscess and teeth extraction.,7 |
| 3448,,38 |
| 560,,22 |
| 3811, Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. ,5 |
| 2625,,5 |
| 8360,,18 |
| 1614, Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.,24 |
| 7853,,19 |
| 6158,Significant discomfort in left lower jaw.,7 |
| 8886,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 |
| 9010,A sample note on Rheumatoid Arthritis,34 |
| 9156,Occupational medicine consult with questions-answers and records review.,18 |
| 6143,"Normal physical exam template. Normocephalic. Negative lesions, negative masses.",25 |
| 4325,"Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.",23 |
| 8439,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 |
| 4132,"Headaches, question of temporal arteritis. Bilateral temporal artery biopsies.",23 |
| 12413,Is it BNP or BMP?,19 |
| 717," Counting calorie points, exercising pretty regularly, seems to be doing well",35 |
| 5834,Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.,8 |
| 7326,"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 |
| 9187,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 |
| 10691,Is it BNP or BMP?,19 |
| 12130,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| |
| |
| |
| Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy. |
| A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. |
| Melena and solitary erosion over a fold at the GE junction, gastric side. |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| 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. |
| |
| |
| |
| |
| |
| |
| Skull, complete, five images. |
| |
| |
| |
| |
| 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.. |
| The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 381, Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.,38 |
| 6768,Thyroid mass diagnosed as papillary carcinoma. The case is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,13 |
| 4554,A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.,10 |
| 10359,Chiropractic Evaluation for neck and low back discomfort following a car accident.,4 |
| 3833," The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.",5 |
| 2346," Consult for hypertension and a med check. History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.",15 |
| 11910,"Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.",4 |
| 4020,Work restrictions and disability evaluation,4 |
| 424," Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.",27 |
| 7834,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 3935, Circumcision procedure in a baby,39 |
| 10069,,36 |
| 5485,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 5632,Extraction of teeth. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,7 |
| 595,,3 |
| 12171,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 2278,,27 |
| 3495,,31 |
| 1513, MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.,22 |
| 4396,Brain CT and MRI - suprasellar mass (pituitary adenoma),33 |
| 9283,,9 |
| 10441,,37 |
| 3727,,3 |
| 9756,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 12283,,34 |
| 1950, The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,12 |
| 5984,,11 |
| 9894,,9 |
| 1514,,15 |
| 9836,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 3176,,21 |
| 237,,38 |
| 9438,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 7131,,37 |
| 11025,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 11999,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 4464,Patient in ER with upper respiratory infection,12 |
| 524, Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 2324, Psychiatric Consultation of patient with recurring depression.,5 |
| 5224,,24 |
| 8951,Consultation for left foot pain.,4 |
| 2680, Creation of right brachiocephalic arteriovenous fistula.,38 |
| 6329,Scleral Buckle opening under general anesthesia.,26 |
| 12261,A sample note on Rheumatoid Arthritis,34 |
| 1997, Urgent cardiac catheterization with coronary angiogram.,12 |
| 3116, Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.,12 |
| 2102,,39 |
| 4734,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 8306,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 |
| 7328,,34 |
| 8383,,7 |
| 1190,,10 |
| 3541, Chronic headaches and pulsatile tinnitus.,11 |
| 9789,,17 |
| 10712,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 10820,,19 |
| 2160,,38 |
| 2131, A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.,5 |
| 7069,,12 |
| 5188,,24 |
| 1063, Small internal hemorrhoids and Ileal colonic anastomosis.,38 |
| 6545,,11 |
| 10425,,9 |
| 3944, MRI Elbow - A middle-aged female complaining of elbow pain.,33 |
| 6765,The client is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,32 |
| 8771,,36 |
| 2720, The patient brought in by EMS with a complaint of a decreased level of consciousness.,15 |
| 26,,31 |
| 678, Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.,27 |
| 10180,Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy,6 |
| 2518, Colpocleisis and rectocele repair.,38 |
| 6889,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 |
| 5574,An example/template for a routine normal female physical exam.,25 |
| 12016,Consultation for left foot pain.,4 |
| 857,,38 |
| 6525,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,12 |
| 1715, Axial images through the cervical spine with coronal and sagittal reconstructions.,33 |
| 9850,,19 |
| 10244,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 |
| 3636, Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.,33 |
| 3848,,11 |
| 1749, Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. ,3 |
| 3703,,15 |
| 12070,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 10247,Preop evaluation regarding gastric bypass surgery.,2 |
| 8800,,18 |
| 8895,Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.,7 |
| 4800,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 |
| 7457,,19 |
| 3152,,31 |
| 9653,,1 |
| 6695,,34 |
| 788,,38 |
| 10880,,9 |
| 9478,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 10010,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 11119,,17 |
| 4237,Decreased ability to perform daily living activities secondary to right knee surgery.,10 |
| 8135,Consult for laparoscopic gastric bypass.,2 |
| 10396,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 5848,,11 |
| 4041,Common description of colonoscopy,14 |
| 3713, Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis. ,38 |
| 1600, Common CT Neck template.,11 |
| 7525,,17 |
| 344, Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.,23 |
| 531, An example/template for a routine normal male physical exam.,25 |
| 6366,,37 |
| 39,,9 |
| 2231,,38 |
| 8084,Consult for laparoscopic gastric bypass.,2 |
| 6843,Acne with folliculitis.,8 |
| 4323,,4 |
| 945,,5 |
| 1328, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,38 |
| 11146,A sample note on Rheumatoid Arthritis,34 |
| 11556,,0 |
| 4219,External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 |
| 1553,,22 |
| 4618,,12 |
| 9253,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 222,,14 |
| 5196,,26 |
| 1862, Left lower extremity venous Doppler ultrasound,3 |
| 1203,,38 |
| 10805,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 6797,,30 |
| 2365, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,10 |
| 6278,,31 |
| 4450,Bilateral renal ultrasound.,21 |
| 2398,,38 |
| 1974,,3 |
| 7910,,20 |
| 1976, Patient comes for discussion of a screening colonoscopy. ,14 |
| 8638,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 10025,,2 |
| 2381,,3 |
| 10040,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 1918, Patient presents complaining of abdominal pain and discomfort for 3 weeks.,15 |
| 5117,Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,32 |
| 12183,A 23-year-old white female presents with complaint of allergies.,0 |
| 9124,Consult for laparoscopic gastric bypass.,2 |
| 5331,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 |
| 9564,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 |
| 10307,Consult for laparoscopic gastric bypass.,2 |
| 12657,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 7508,"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 |
| 10131,The client 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 |
| 7600,Mother states he has been wheezing and coughing.,0 |
| 8960,,13 |
| 11945,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 9291,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 2482, MRI left knee without contrast.,27 |
| 3802,,15 |
| 3017,,27 |
| 7517,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 10420,,0 |
| 4610,,30 |
| 5758,A 9-month well-child check.,29 |
| 1780, Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,3 |
| 9239,,9 |
| 8405,,9 |
| 6877,A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,12 |
| 3207,,5 |
| 7431,,19 |
| 1962,,38 |
| 610, Iron deficiency anemia. Diverticulosis in the sigmoid.,14 |
| 1012, Sample cardiology office visit note.,3 |
| 8454,,7 |
| 10210,MRI report Cervical Spine (Chiropractic Specific),4 |
| 9105,Preop evaluation regarding gastric bypass surgery.,2 |
| 1308, Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.,27 |
| 7742,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 |
| 6111,Right ear discomfort with drainage - otitis media and otorrhea.,11 |
| 8820,,36 |
| 8863,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 9941,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 |
| 10561,,37 |
| 99, Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. ,3 |
| 6962,Bilateral myringotomy tubes and adenoidectomy.,11 |
| 8770,,36 |
| 7393,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 647,,38 |
| 11251,,36 |
| 7713,,25 |
| 2751,,27 |
| 7073,Right foot series after a foot injury.,31 |
| 12073,Consultation for wrist pain.,4 |
| 6447,Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal ache for the last 14 days.,12 |
| 6224,Consult for laparoscopic gastric bypass.,2 |
| 2287,,3 |
| 205,,10 |
| 10027,,8 |
| 2267, A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. ,33 |
| 3551, MRI - Arteriovenous malformation with hemorrhage.,22 |
| 8544,,30 |
| 8385,,7 |
| 2017, Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,22 |
| 2872,,32 |
| 6845,Acne with folliculitis.,8 |
| 5160,,25 |
| 9460,Mother states he has been wheezing and coughing.,0 |
| 496, Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 |
| 837, Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 |
| 1797, Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 |
| 9224,Cause of death - Anoxic Encephalopathy,1 |
| 8045,,2 |
| 203,,38 |
| 1008, Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps. ,14 |
| 5537,,23 |
| 2992, Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.,11 |
| 2741, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,35 |
| 845, Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.,27 |
| 11531,Work restrictions and disability evaluation,4 |
| 2561, Open cholecystectomy (attempted laparoscopic cholecystectomy).,38 |
| 9514,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 7271,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 2876,,38 |
| 12420,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 7074,Right foot series after a foot injury.,31 |
| 11328,,30 |
| 265,,38 |
| 9203,Evaluation for chronic ache program,4 |
| 7066,Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,6 |
| 9200,Consultation for wrist pain.,4 |
| 240, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 |
| 7814,,6 |
| 1198, Psychiatric consultation for management of pain medications.,32 |
| 492, Ultrasound Abdomen - elevated liver function tests.,33 |
| 6374,Well child - Left lacrimal duct stenosis,29 |
| 12319,,17 |
| 6575,Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,23 |
| 1422, |
| ,29 |
| 1601,,38 |
| 6271,She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.,26 |
| 6952,Initial evaulation - neck and back pain.,4 |
| 4173,,14 |
| 8856,,30 |
| 1483, An example/template for a routine normal female physical exam.,15 |
| 10275,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 11979,Is it BNP or BMP?,19 |
| 1916, Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.,24 |
| 4882,,39 |
| 9973,,7 |
| 840, Left retrosigmoid craniotomy and excision of acoustic neuroma.,22 |
| 7847,Work restrictions and disability evaluation,18 |
| 3082, Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 |
| 1539,,27 |
| 3032, Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.,38 |
| 3145,,26 |
| 6221,Admission Psychiatric Evaluation,32 |
| 12402,,18 |
| 6675,Cervical epidural steroid injection C7-T1. An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,28 |
| 5346,Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.,11 |
| 2619,,27 |
| 12287,,34 |
| 8729,Work restrictions and disability evaluation,18 |
| 1585, Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.,22 |
| 6844,Acne with folliculitis.,8 |
| 10406,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 5647,,23 |
| 5185,,21 |
| 109,,35 |
| 651,,38 |
| 10620,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 3153, Colpocleisis and rectocele repair.,24 |
| 5879,Bilateral temporal artery biopsy. Rule out temporal arteritis.,23 |
| 4224,Patient with episode of lightheadedness and suddenly experienced vertigo.,22 |
| 5077,Extensive stage small cell lung cancer. Chemotherapy with carboplatin and etoposide. Left scapular discomfort status post CT scan of the thorax.,16 |
| 6434,Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,11 |
| 10692,Is it BNP or BMP?,19 |
| 1368, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 |
| 9532,,0 |
| 1282, Unilateral transpedicular T11 vertebroplasty.,27 |
| 4019,,7 |
| 523, Laparoscopic cholecystectomy.,38 |
| 2480, She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,24 |
| 3903, Patient with palpitations and rcent worsening of chronic chest discomfort.,3 |
| 2480, She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.,24 |
| 5585,Pediatric Gastroenterology - History of gagging.,29 |
| 3280, Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister. ,8 |
| 2805,,8 |
| 4822,A white female presents for exam and Pap.,24 |
| 2587,,24 |
| 4344,,14 |
| 11241,,6 |
| 4958,,36 |
| 8167,Preoperative visit for weight management with laparoscopic gastric banding,2 |
| 9088,,19 |
| 9047,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 6614,,21 |
| 3695, Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,3 |
| 8659,,36 |
| 7695,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 9506,,19 |
| 3431, Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones.,5 |
| 5757,A 9-month well-child check.,29 |
| 5637,Patient had a markedly abnormal stress test with severe chest discomfort after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,25 |
| 11437,,37 |
| 8218,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 |
| 4904,,12 |
| 4657,A 65-year-old man with chronic prostatitis returns for recheck.,39 |
| 4620,,12 |
| 5358,Nephrology office visit for followup of CKD.,25 |
| 8183,Cause of death - Anoxic Encephalopathy,1 |
| 2207, Patient presents for a colostomy reversal as well as repair of an incisional hernia. ,5 |
| 4738,,26 |
| 8968,Mother states he has been wheezing and coughing.,0 |
| 2080, Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,5 |
| 6498,,21 |
| 115, 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.,5 |
| 12290,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 7811,,36 |
| 7627,,34 |
| 8754,Occupational medicine consult with questions-answers.,18 |
| 1340, Patient in ER complaining of shortness of breath (COPD),3 |
| 2683,,38 |
| 3402, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,38 |
| 11529,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 4572,A woman presents for neurological evaluation with regards to a identification of multiple sclerosis.,22 |
| 6850,Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.,26 |
| 7913,,19 |
| 3358, MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,27 |
| 8386,,7 |
| 7253,,19 |
| 8136,Consult for laparoscopic gastric bypass.,2 |
| 902, Neurologic consultation was requested to assess and assist with seizure medication.,5 |
| 7828,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 4309,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 3285, Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,5 |
| 7200,,18 |
| 5775,The client was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.,32 |
| 9429,Is it BNP or BMP?,19 |
| 2727, Twin pregnancy with threatened preterm labor.,24 |
| 4639,,24 |
| 7077,Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.,2 |
| 8954,,13 |
| 3752, Circumcision procedure (neotal),39 |
| 9660,,1 |
| 6591,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,31 |
| 9035,,9 |
| 6043,,23 |
| 1638, CT scan of the abdomen and pelvis without and with intravenous contrast.,21 |
| 2843,,7 |
| 2869,,24 |
| 6446,Patient today with ongoing issues with diabetic control.,13 |
| 2171,,3 |
| 4933,,39 |
| 867,,16 |
| 7415,Is it BNP or BMP?,19 |
| 6036,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 3203,,24 |
| 4247,Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal.,14 |
| 10422,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 |
| 5479,Trauma/ATV accident resulting in left open humerus fracture.,10 |
| 9019,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 12653,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 10108,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 10039,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 9564,,0 |
| 777, MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,22 |
| 1675,,24 |
| 9180,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 5475,,24 |
| 12388,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 7256,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 469,,35 |
| 10228,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and ache to the left lower mandible area today.,7 |
| 6755,The case is being referred for evaluation of diabetic retinopathy.,26 |
| 2293, Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.,38 |
| 10740,,19 |
| 7579,Is it BNP or BMP?,19 |
| 5973,Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid therapy to left lateral nasal skin 2.5 cm to treat actinic keratosis.,8 |
| 5916,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.,13 |
| 7804,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 7630,,34 |
| 11525,Elevated cholesterol and is on medication to lower it.,9 |
| 9495,,19 |
| 1509, Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,16 |
| 11688,Mother states he has been wheezing and coughing.,0 |
| 10681,Dietary consultation for gestational diabetes.,9 |
| 8814,Occupational medicine consult with questions-answers and records review.,18 |
| 11324,,19 |
| 7635,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 6636,,21 |
| 11492,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 624,,5 |
| 8731,Evaluation for bariatric surgery.,2 |
| 7196,Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,32 |
| 269, CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,11 |
| 7386,The case was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The case 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 case to achieve hands-free voicing.,37 |
| 4364,Patient dropped a weight on the dorsal aspects of his feet.,31 |
| 6988,Small office note on premature retina and vitreous.,26 |
| 10168,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 10758,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 3084,,27 |
| 4504,Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.,31 |
| 5831,,10 |
| 12023,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 1871, Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. ,32 |
| 10765,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 3302, She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.,38 |
| 2828, A 75-year-old female comes in with concerns of having a stroke.,22 |
| 3230, Dental restorations and extractions. Dental caries. He has had multiple severe carious lesions that warrant multiple extractions at this time.,38 |
| 1329, Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.,38 |
| 5626,,39 |
| 2060,,15 |
| 9173,,37 |
| 461, Laparoscopic cholecystectomy with cholangiogram.,38 |
| 5965,Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.,21 |
| 10206,A 21-channel digital electroencephalogram was performed on a case in the awake state.,36 |
| 3380,,28 |
| 7868,Dietary consultation for gestational diabetes.,9 |
| 5262,,11 |
| 6993,,21 |
| 7694,Procedure note on Keller Bunionectomy,31 |
| 8740,,19 |
| 4090,Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.,39 |
| 9730,,34 |
| 8675,,2 |
| 1045,,28 |
| 10514,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 |
| 2945, Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.,5 |
| 1501,,38 |
| 11083,,34 |
| 2433,,38 |
| 12038,,9 |
| 10, Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,3 |
| 12529,,0 |
| 4257,,24 |
| 11861,,34 |
| 11434,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 555, Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.,14 |
| 8737,Evaluation for bariatric surgery.,2 |
| 9190,Consult for laparoscopic gastric bypass.,2 |
| 7521,,17 |
| 10370,Qualified medical evaluation report of a client with back pain.,18 |
| 4689,1-month-old for a healthy checkup - Well child check,29 |
| 11147,A sample note on Rheumatoid Arthritis,34 |
| 8772,,36 |
| 10853,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 8289,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 11804,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 10134,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 |
| 3546,,27 |
| 2771,,5 |
| 9675,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 7770,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 5950,Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,8 |
| 392, Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.,23 |
| 4387,Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,23 |
| 10398,Incision and drainage of right buccal space abscess and teeth extraction.,7 |
| 6053,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent identification of urinary tract infection on outpatient treatment with nitrofurantoin.,10 |
| 6852,,11 |
| 10883,,9 |
| 4864,,26 |
| 12335,A sample note on Rheumatoid Arthritis,34 |
| 1981, Right and Left carotid ultrasound ,3 |
| 598,,27 |
| 7502,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 3722,,24 |
| 6707,,20 |
| 4225,Patient with episode of lightheadedness and suddenly experienced vertigo.,22 |
| 12043,Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,4 |
| 4799,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 |
| 7769,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 8065,Significant discomfort in left lower jaw.,7 |
| 5987,Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,23 |
| 1058, Possible cerebrovascular accident. The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. ,22 |
| 3835,,38 |
| 1023,,5 |
| 9471,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 2303, Right heart catheterization. Refractory CHF to maximum medical therapy.,3 |
| 12418,Dietary consultation for diabetes during pregnancy.,9 |
| 254,,33 |
| 9080,,19 |
| 9365,,0 |
| 8011,A sample note on Rheumatoid Arthritis,34 |
| 8340,,37 |
| 4571,A woman presents for neurological evaluation with regards to a determination of multiple sclerosis.,22 |
| 10855,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 10797,,9 |
| 6966,,21 |
| 2763, 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.,6 |
| 6542,,32 |
| 2153,,27 |
| 7558,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 7853,,19 |
| 12552,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 913, Flexible Sigmoidoscopy.,14 |
| 8719,A 23-year-old white female presents with complaint of allergies.,0 |
| 9561,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 10530,Occupational medicine consult with questions-answers and records review.,18 |
| 11980,Is it BNP or BMP?,19 |
| 11698,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 1409, Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,27 |
| 12651,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 8495,,7 |
| 1345, An example/template for a routine normal female physical exam.,5 |
| 6276,,31 |
| 2731,,21 |
| 7439,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 1352, Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina.,3 |
| 9752,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 1085,,4 |
| 8289,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 7660,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 4093,,24 |
| 7295,,17 |
| 12144,,0 |
| 474, Most commonly used phrases in physical exam.,5 |
| 2986,,11 |
| 3374,,22 |
| 165, Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 |
| 3756,,15 |
| 12019,,13 |
| 12165,,1 |
| 12099,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 7173,,13 |
| 3183, Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.,14 |
| 9299,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 3464,,38 |
| 7659,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 1240,,5 |
| 552,,27 |
| 3385, Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage,38 |
| 2854,,39 |
| 11003,A 23-year-old white female presents with complaint of allergies.,0 |
| 7790,,6 |
| 2341,,31 |
| 4446,Followup circumcision. The client had a pretty significant phimosis and his operative course was smooth. Satisfactory course after circumcision for severe phimosis with no perioperative complications.,39 |
| 8503,,37 |
| 1989, Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. ,35 |
| 9711,A sample note on Rheumatoid Arthritis,34 |
| 12412,Is it BNP or BMP?,19 |
| 8972,,30 |
| 230,,3 |
| 901,,38 |
| 12563,A 23-year-old white female presents with complaint of allergies.,0 |
| 11983,,18 |
| 10844,,37 |
| 11887,Work restrictions and disability evaluation,4 |
| 6230,,23 |
| 11384,,9 |
| 2489, Migraine headache - The patient was seen in the urgent care.,12 |
| 4161,Status post brain tumor removal. The case 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 |
| 1276,,27 |
| 10298,Completion thyroidectomy with limited right paratracheal node dissection.,13 |
| 2402,,12 |
| 11638,Is it BNP or BMP?,19 |
| 4348,,21 |
| 7495,,9 |
| 7447,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 2902," Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.",38 |
| 4021,Work restrictions and disability evaluation,4 |
| 1482, Endoscopic carpal tunnel release. Left carpal tunnel syndrome.,27 |
| 1306," Laparoscopic cholecystectomy. Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.",14 |
| 8817,Occupational medicine consult with questions-answers and records review.,18 |
| 8700,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. |
| |
| |
| |
| |
| |
| Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. |
| |
| Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The case was given discharge instructions on wound care. |
| |
| Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder. |
| |
| |
| |
| Specimen labeled right ovarian cyst is received fresh for frozen section. |
| Left thyroid mass. Left total thyroid lumpectomy. The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. |
| Status post brain tumor with removal. The patient 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. |
| Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease. |
| |
| Normal physical exam template. Well developed, well nourished, in no acute distress. |
| |
| Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size. Recurrent bladder tumor and history of bladder carcinoma. |
| Acute foot or ankle sprain, possible small fracture. |
| |
| |
| |
| |
| |
| Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. |
| Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. |
| |
| |
| 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. |
| |
| |
| Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis. |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 6940,"Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.",31 |
| 9036,"The client has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 |
| 3787," Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.",3 |
| 3981, Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,3 |
| 4298,"The case is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. He is on his eighth hospital day.",35 |
| 1595, Adenoidectomy procedure,11 |
| 2675, Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.,38 |
| 6055,A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient therapy with nitrofurantoin.,10 |
| 10427,"Total thyroidectomy. The client is a female with a history of Graves disease. Suppression was attempted, however, unsuccessful. She presents today with her thyroid goiter.",13 |
| 6807,Thyroid mass diagnosed as papillary carcinoma. The client is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,16 |
| 9079,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 5444,Hand dermatitis.,8 |
| 8521,Chiropractic IME with answers to questions from Insurance Company.,20 |
| 2648," Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.",14 |
| 7019,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 |
| 9735,"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 |
| 11514,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. |
| |
| |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 3467, Cervical Selective Nerve Root Block,28 |
| 4510,"Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.",14 |
| 7166,"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.",18 |
| 3910, Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,38 |
| 2463," Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.",10 |
| 10653,A 23-year-old white female presents with complaint of allergies.,0 |
| 3333," A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. ",5 |
| 1346, Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.,38 |
| 4440,"Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.",35 |
| 2390, A 27-year-old female with a size and date discrepancy.,24 |
| 10278,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 |
| 4367,"Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy. |
| |
| |
| |
| |
| He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. |
| Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. |
| 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. |
| Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy. |
| |
| |
| The case is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission. |
| Patient with a history of PTSD, depression, and substance abuse. |
| |
| This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. |
| |
| |
| Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation |
| |
| Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy. |
| |
| C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy. |
| Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter. |
| |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained. |
| Patient suffers from neck and lower back ache radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms. |
| |
| |
| Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty. Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis. |
| Specimen labeled sesamoid bone left foot. |
| Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst. |
| |
| |
| Followup diabetes mellitus, type 1. |
| |
| |
| Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. |
| |
| 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. |
| |
| |
| |
| Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. |
| |
| |
| |
| Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. |
| |
| |
| Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. |
| |
| Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. |
| |
| The case with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand. |
| |
| |
| The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. |
| 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 |
| 6741,Removal of the old right pressure equalizing tube. Myringotomy with placement of a left pressure equalizing tube.,11 |
| 11427,Occupational medicine consult with questions-answers and records review.,18 |
| 5305,Stage I and II neuromodulator.,39 |
| 5126,Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,23 |
| 11997,"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 discomfort that radiates from her back into her legs. She has had no associated weakness.",30 |
| 12662,A sample note on Rheumatoid Arthritis,34 |
| 9076,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 4103,MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,22 |
| 5328,Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.,11 |
| 11807,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 6456,Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.,36 |
| 10297,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 7477,Cause of death - Anoxic Encephalopathy,1 |
| 7836,"The skin biopsy was performed on the right ankle and right thigh. The case was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.",8 |
| 8120,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 |
| 11954,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 |
| 9758,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 3775," Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.",5 |
| 4667,"Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.",16 |
| 11268,A 23-year-old white female presents with complaint of allergies.,0 |
| 10561,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. |
| Followup diabetes mellitus, type 1. |
| |
| |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 8625,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 1007," Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine. Nondiagnostic dobutamine stress test. Normal nuclear myocardial perfusion scan.",3 |
| 5440,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 |
| 5354,Patient in ER due to colostomy failure - bowel obstruction.,12 |
| 7704,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 |
| 7503,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. |
| |
| |
| Incision and drainage, first metatarsal head, left foot with culture and sensitivity. |
| |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| |
| C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. |
| |
| |
| |
| |
| |
| Well-child check sports physical - Well child asthma with good control, allergic rhinitis. |
| |
| |
| |
| True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. |
| |
| Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 |
| 3839, Endovascular Brachytherapy (EBT),33 |
| 8076,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 |
| 5921,Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.,26 |
| 5947,A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,16 |
| 9365,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 3295, Consultation - an 87-year-old white female with weakness and a history of polymyositis.,5 |
| 7361,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with identification of CVA with right hemiparesis.,30 |
| 2021," CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.",33 |
| 4957,"Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.",36 |
| 1803, Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,38 |
| 6247,Patient presents with a chief complaint of chest discomfort admitted to Coronary Care Unit due to acute inferior myocardial infarction.,12 |
| 9275,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 |
| 6274,An example/template for a routine normal male physical exam.,25 |
| 9406,A 23-year-old white female presents with complaint of allergies.,0 |
| 8585,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 9510,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 |
| 2025," The patient 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.",5 |
| 10886,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 |
| 2291, Prostate adenocarcinoma and erectile dysfunction - Pathology report.,39 |
| 5405,"Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",21 |
| 1235, Bilateral vasovasostomy surgery sample.,39 |
| 10807,"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 |
| 9311,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. |
| |
| External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. |
| |
| Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma. |
| |
| Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea. |
| Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye. |
| Questionable foreign body, right nose. Belly and back pain. Mild constipation. |
| |
| First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.",18 |
| 8768,"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.",36 |
| 8517,Chiropractic IME with answers to questions from Insurance Company.,20 |
| 4045,CT Brain: Midbrain hemangioma,33 |
| 2176, Carotid Ultrasonic & Color Flow Imaging,33 |
| 8629,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 2495," Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.",35 |
| 1133, Left distal medial hamstring release.,27 |
| 11613,A 23-year-old white female presents with complaint of allergies.,0 |
| 3255, Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.,24 |
| 848," This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. ",12 |
| 4827,A 31-year-old white female admitted to the hospital with pelvic discomfort and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 |
| 7685,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 12426,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 |
| 11292,Is it BNP or BMP?,19 |
| 9786,,17 |
| 2636, This patient has reoccurring ingrown infected toenails.,38 |
| 3321,,27 |
| 1679,,14 |
| 8163,,0 |
| 2387, Dental prophylaxis under general anesthesia.,38 |
| 1113,,24 |
| 1453, 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.,38 |
| 8246,,20 |
| 4355,,14 |
| 10266,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 |
| 3967,,38 |
| 10795,,9 |
| 11968,Evaluation for bariatric surgery.,2 |
| 6941,,31 |
| 6486,The client continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,25 |
| 6824,,21 |
| 11600,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 10356,Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,7 |
| 384, Right pontine pyramidal tract infarct.,33 |
| 6191,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 |
| 3391, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,38 |
| 11049,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 2222, Full mouth dental rehabilitation in the operating room under general anesthesia.,7 |
| 8723,Work restrictions and disability evaluation,18 |
| 3147, Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,5 |
| 2317, MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,33 |
| 4316,Whole body radionuclide bone scan due to prostate cancer.,33 |
| 9960,,30 |
| 417, Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,11 |
| 10354,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.,18 |
| 1359, CT scan of the abdomen and pelvis without and with intravenous contrast.,14 |
| 5144,Work restrictions and disability evaluation,18 |
| 1171,,14 |
| 2927, Chest pain. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.,3 |
| 11066,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 |
| 1736, Underwent tonsillectomy and adenoidectomy two weeks ago. ,25 |
| 9077,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 10062,,19 |
| 11337,,13 |
| 32, Normal Circumcision,39 |
| 116, Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.,38 |
| 7938,,13 |
| 9242,,34 |
| 654,,3 |
| 837, Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.,32 |
| 7714,,25 |
| 10290,,6 |
| 2709,,38 |
| 10558,,37 |
| 12169,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 418,,38 |
| 1824,,10 |
| 9435,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 11318,,30 |
| 6530,Plantar fascitis/heel spur syndrome. The case was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.,31 |
| 7114,,28 |
| 7391,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 6735,Patient scheduled for laparoscopic gastric bypass.,2 |
| 10001,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 |
| 2825,,38 |
| 1461, Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,3 |
| 11595,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 5621,A simple note on Acne Vulgaris.,8 |
| 10775,A sample note on Rheumatoid Arthritis,34 |
| 9598,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 811,,5 |
| 5035,Psychiatric Consultation of client with anxiety.,32 |
| 4073,Primary low-transverse cesarean section.,24 |
| 6942,,31 |
| 2970, Closure of gastrostomy placed due to feeding difficulties. ,38 |
| 5233,,28 |
| 7510,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 6,,3 |
| 7881,,4 |
| 5394,Patient complains of chest ache - possible esophageal reflux,12 |
| 2631,,26 |
| 8704,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 5406,"Skull, complete, five images.",29 |
| 7387,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 599, Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.,38 |
| 3341," Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.",38 |
| 12071,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 1167," Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy",21 |
| 7583,Is it BNP or BMP?,19 |
| 3871, MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,33 |
| 10039,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 3186, Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.,27 |
| 10001,Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures,8 |
| 207, Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,38 |
| 3970, Left laparoscopic hand-assisted nephrectomy.,21 |
| 8112,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 4005,MRI Brain: Thrombus in torcula of venous sinuses.,33 |
| 6001,Injection of bilateral carpal tunnels,28 |
| 10225,,20 |
| 5385,,24 |
| 8252,,7 |
| 865,,38 |
| 11519,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 10492,,17 |
| 3844,,31 |
| 4167,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 |
| 7155,Patient dropped a weight on the dorsal aspects of his feet.,12 |
| 7461,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 7350,,9 |
| 7888,,36 |
| 4227,Resting Myoview and adenosine Myoview SPECT,33 |
| 4589,,28 |
| 12080,,9 |
| 3269,,35 |
| 2117,,21 |
| 1744,,5 |
| 6651,,11 |
| 281, Bilateral renal ultrasound.,21 |
| 8068,,6 |
| 6484,Falls at home. Anxiety and depression. The client had been increasingly anxious and freely admitted that she was depressed at home.,32 |
| 6505,,11 |
| 7547,,1 |
| 6025,,28 |
| 6324,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.,12 |
| 12245,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 6146,Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,13 |
| 228, Perlane injection for the nasolabial fold. Restylane injection for the glabellar fold.,38 |
| 7709,Occupational medicine consult with questions-answers and records review.,18 |
| 80, LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,24 |
| 12221,,19 |
| 9882,Mother states he has been wheezing and coughing.,0 |
| 12603,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 2394,,6 |
| 5058,Burr hole and insertion of external ventricular drain catheter.,23 |
| 4376,,7 |
| 11232,,30 |
| 226,,38 |
| 1476, Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.,5 |
| 331,,15 |
| 3682,,31 |
| 6032,,9 |
| 9901,,9 |
| 11592,The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client 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 client to achieve hands-free voicing.,37 |
| 12331,A sample note on Rheumatoid Arthritis,34 |
| 6578,Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,23 |
| 9880,Mother states he has been wheezing and coughing.,0 |
| 11206,,37 |
| 4423,Left axillary lymph node excisional biopsy. Left axillary adenopathy.,16 |
| 1675,,24 |
| 6030,Urgent cardiac catheterization with coronary angiogram.,12 |
| 10862,,0 |
| 9401,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 9632,,17 |
| 10742,,19 |
| 1275,,38 |
| 10304,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 |
| 12423,,19 |
| 4361,Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,14 |
| 10227,This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and discomfort to the left lower mandible area today.,7 |
| 12612,A sample note on Rheumatoid Arthritis,34 |
| 7027,Diagnosis of benign rolandic epilepsy.,20 |
| 9120,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 |
| 5411,,26 |
| 12609,A sample note on Rheumatoid Arthritis,34 |
| 9512,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 825,,38 |
| 3314,,27 |
| 6798,,31 |
| 4942,,35 |
| 4898,,21 |
| 95, The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.,15 |
| 861,,5 |
| 3070, Patient scheduled for laparoscopic gastric bypass. ,2 |
| 17,,23 |
| 2282,,13 |
| 11121,,17 |
| 5994,A 21-channel digital electroencephalogram was performed on a client in the awake state.,36 |
| 88, Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,38 |
| 29, Foul-smelling urine and stomach pain after meals.,14 |
| 1261,,15 |
| 12525,,17 |
| 55,,39 |
| 8894,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 |
| 1138," Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.",10 |
| 272, Upper endoscopy with foreign body removal (Penny in proximal esophagus).,14 |
| 1624, Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,38 |
| 7279,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 5400,An example of a physical exam,25 |
| 10883,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 |
| 10978,"Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.",0 |
| 180, Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 97, Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 |
| 7589,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 2698," Left buttock abscess, status post incision and drainage. Recommended some local wound care",8 |
| 11884,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 7524,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss. |
| Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids. |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. |
| |
| Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. |
| Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. |
| Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. |
| |
| |
| This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. |
| Ultrasound abdomen, complete |
| |
| Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region. |
| Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck discomfort and left low back pain. |
| |
| Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 |
| Excision of nasal tip basal carcinoma, previous positive biopsy. |
| |
| |
| |
| Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three. |
| |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| |
| |
| Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. |
| Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. |
| |
| |
| |
| |
| |
| Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis. |
| |
| A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. |
| |
| |
| |
| |
| Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System. |
| Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc. |
| |
| |
| Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used. |
| Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. |
| |
| |
| |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative healthcare therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis. |
| |
| Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. |
| |
| Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged. |
| |
| |
| |
| |
| EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, |
| |
| |
| |
| |
| |
| |
| |
| Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye. |
| |
| |
| |
| |
| EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. |
| |
| |
| |
| |
| |
| Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. |
| |
| Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. |
| Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him. |
| |
| |
| Cerebrovascular accident (CVA). The case presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. |
| Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. |
| |
| Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5. |
| |
| Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. |
| |
| 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 discomfort that radiates from her back into her legs. She has had no associated weakness. |
| Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 |
| 10050,Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.,6 |
| 10309,Consult for laparoscopic gastric bypass.,2 |
| 1748," A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. ",5 |
| 8296,Diagnosis of benign rolandic epilepsy.,20 |
| 4838,Nephrology office visit for followup of microscopic hematuria.,21 |
| 5373,Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 |
| 12246,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 11963,Work restrictions and disability evaluation,18 |
| 1787," Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.",3 |
| 10041,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 4341,,14 |
| 1005,,5 |
| 7887,,36 |
| 2170, Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.,38 |
| 10633,,2 |
| 10835,Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.,9 |
| 7941,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 |
| 411,,38 |
| 12254,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 3460, Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.,38 |
| 11949,,36 |
| 2786, Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,14 |
| 316, Psychiatric evaluation for major depression without psychotic features.,32 |
| 9340,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 10648,,18 |
| 2280,,5 |
| 7823,,36 |
| 4052,,31 |
| 7281,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 6273,An example/template for a routine normal male physical exam.,25 |
| 9287,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 2746,,11 |
| 705, Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,38 |
| 3199, Brain CT and MRI - suprasellar mass (pituitary adenoma),22 |
| 8491,,7 |
| 10436,,37 |
| 6553,The case has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 |
| 12245,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 1830,,3 |
| 3547, MRI left knee without contrast.,33 |
| 1339, Psychiatric consultation for substance abuse.,32 |
| 7527,,17 |
| 2128, MRI Elbow - A middle-aged female complaining of elbow pain.,27 |
| 4544,,14 |
| 1334, MRI report Cervical Spine (Chiropractic Specific),33 |
| 8524,Chiropractic IME with answers to questions from Insurance Company.,20 |
| 2552, Consultation for evaluation of thrombocytopenia.,15 |
| 12050,,19 |
| 8933,,13 |
| 12216,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 2196,,5 |
| 9733,,34 |
| 163,,21 |
| 5418,Patient referred for narrow angles and possible associated glaucoma.,26 |
| 6192,Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,26 |
| 10367,,34 |
| 3041, Anterior cranial vault reconstruction with fronto-orbital bar advancement.,38 |
| 259, Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. ,38 |
| 10013,,6 |
| 3318,,5 |
| 11798,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 8417,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 3237, Pelvic Pain and vaginal discharge,5 |
| 3840, 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.,15 |
| 12626,,34 |
| 10020,,36 |
| 10185,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 6137,,32 |
| 11136,,17 |
| 2142,,21 |
| 3737, Common CT C-Spine template,33 |
| 7744,,1 |
| 2520, Common description of colonoscopy,38 |
| 8976,,30 |
| 2507,,21 |
| 11382,,9 |
| 9633,,17 |
| 9723,,34 |
| 10485,,17 |
| 6173,,19 |
| 9489,A sample note on Rheumatoid Arthritis,34 |
| 3412,,31 |
| 10239,Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.,36 |
| 7789,,6 |
| 5284,,39 |
| 922,,38 |
| 3134, Flexible bronchoscopy to evaluate the airway (chronic wheezing).,3 |
| 5820,Discharge summary of a client with depression and high risk behavior.,32 |
| 5093,,11 |
| 627,,26 |
| 6520,,8 |
| 9930,Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.,8 |
| 9768,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 5273,,23 |
| 9365,,0 |
| 12011,,19 |
| 11559,,0 |
| 6166,Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,29 |
| 745,,10 |
| 1724, MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),33 |
| 6872,,26 |
| 10057,Evaluation for bariatric surgery.,2 |
| 1044, Spermatocelectomy and orchidopexy,38 |
| 2630, Tonsillectomy and adenoidectomy. Chronic adenotonsillitis. The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. ,38 |
| 725,,27 |
| 2108,,3 |
| 891, Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.,38 |
| 8569,,20 |
| 10528,,0 |
| 3166,,38 |
| 11473,,9 |
| 551, Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.,38 |
| 6994,,31 |
| 9734,,34 |
| 6550,,16 |
| 4308,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 1451, Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain,25 |
| 11263,,18 |
| 12513,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 7933,Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,6 |
| 2145, Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,3 |
| 11825,,17 |
| 6753,The case is being referred for evaluation of diabetic retinopathy.,26 |
| 4526,,26 |
| 6955,Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with identification of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,29 |
| 10682,Dietary consultation for gestational diabetes.,9 |
| 8344,,37 |
| 198,,15 |
| 7576,,19 |
| 4915,Right orchiopexy and right inguinal hernia repair.,39 |
| 8627,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 5528,Bilateral tympanostomy with myringotomy tube placement. The client is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.,29 |
| 1487, Left partial nephrectomy due to left renal mass.,38 |
| 7278,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 1505,,14 |
| 8158,Evaluation for chronic discomfort program,4 |
| 11910,,4 |
| 7684,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 7023,An example/template for a routine normal female physical exam.,25 |
| 11791,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 2623,,27 |
| 651,,38 |
| 4452,,24 |
| 8066,,6 |
| 5281,,21 |
| 12249,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 5546,Marked right hydronephrosis without hydruria.,21 |
| 5146,Evaluation for bariatric surgery.,2 |
| 10918,,0 |
| 2956, Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. ,14 |
| 1639, 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.,5 |
| 8845,Dietary consultation for diabetes during pregnancy.,9 |
| 2113,,31 |
| 869,,8 |
| 3076,,5 |
| 7152,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 4940,Left retrosigmoid craniotomy and excision of acoustic neuroma.,23 |
| 9486,A sample note on Rheumatoid Arthritis,34 |
| 4716,,35 |
| 704, Sample female review of systems.,15 |
| 4499,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 |
| 5373,Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,25 |
| 2435,,26 |
| 8353,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 6419,,23 |
| 4039,Total colonoscopy with biopsy and snare polypectomy.,14 |
| 6205,Full mouth dental rehabilitation in the operating room under general anesthesia.,7 |
| 2560,,29 |
| 4985,Patient with fever of unknown origin.,10 |
| 6908,Plantar Fascia Injection,28 |
| 1810,,15 |
| 1367,,38 |
| 8762,,36 |
| 755,,27 |
| 12511,Elevated cholesterol and is on medication to lower it.,9 |
| 832, Psychosocial Evaluation of patient before kidney transplant.,32 |
| 4979,,8 |
| 1231, Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.,33 |
| 894,,33 |
| 7322,A sample note on Rheumatoid Arthritis,34 |
| 12195,,19 |
| 4458,Sample Radiology report of knee (growth arrest lines).,33 |
| 9439,,19 |
| 1703, Left spermatocelectomy/epididymectomy and bilateral partial vasectomy. Left spermatocele and family planning.,39 |
| 7032,Dental restoration. Dental caries. Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.,7 |
| 5533,A female with unknown gestational age who presents to the ED after a suicide attempt.,12 |
| 3948, Evaluation and recommendations regarding facial rhytids.,8 |
| 6806,,28 |
| 1734, Discharge summary of a patient with depression and high risk behavior.,32 |
| 12615,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 4140,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 245, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,35 |
| 12204,Is it BNP or BMP?,19 |
| 961,,38 |
| 66,,23 |
| 10412,Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,36 |
| 10339,Preoperative visit for weight management with laparoscopic gastric banding,2 |
| 7551,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 9448,,19 |
| 10100,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 |
| 9225,Cause of death - Anoxic Encephalopathy,1 |
| 7285,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 3348, Complete heart block with pacemaker malfunction and a history of Shone complex.,12 |
| 4255,Urine leaked around the ostomy site for his right sided nephrostomy tube. The client had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,21 |
| 3240, Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. ,5 |
| 1948,,15 |
| 10518,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 11371,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.,13 |
| 9953,,7 |
| 1636, Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,22 |
| 7448,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 2556, An example normal physical exam,25 |
| 12386,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 659, Antibiotic management for a right foot ulcer and possible osteomyelitis.,5 |
| 6056,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,25 |
| 6000,Injection of bilateral carpal tunnels,28 |
| 430, Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection. Right buccal space infection and abscess tooth #T.,38 |
| 3959," Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.",38 |
| 4368,"Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy. |
| |
| Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change. |
| |
| |
| |
| |
| A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. |
| |
| Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum |
| |
| Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and therapy planning. |
| |
| Autologous iliac crest bone graft to maxilla and mandible under general anesthetic. Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction. |
| Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.",17 |
| 5940,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 3291,,39 |
| 7641,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 350, An example/template for a routine normal male physical exam.,25 |
| 4078,MRI Cervical Spine without contrast.,33 |
| 3738,,38 |
| 6896,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 12095,,9 |
| 6792,,26 |
| 1933,,38 |
| 12519,,17 |
| 9589,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 8313,,0 |
| 4389,,37 |
| 5335,Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.,12 |
| 4638,Right argon laser assisted stapedectomy. Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,11 |
| 8091,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 5546,Marked right hydronephrosis without hydruria.,21 |
| 5219,,21 |
| 8942,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 9075,Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.,37 |
| 6223,Admission Psychiatric Evaluation,32 |
| 4327,,23 |
| 10630,,36 |
| 4034,,23 |
| 11736,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 11512,Autopsy - Asphyxia due to ligature strangulation.,1 |
| 4119,Closure of gastrostomy placed due to feeding difficulties.,14 |
| 6685,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,20 |
| 12378,,1 |
| 12468,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 4388,,37 |
| 11830,,17 |
| 7674,,9 |
| 11459,,0 |
| 4988,Consultation for ICU management for a case with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.,12 |
| 8758,,36 |
| 3718, Central line insertion. Empyema thoracis and need for intravenous antibiotics.,38 |
| 12256,A sample note on Rheumatoid Arthritis,34 |
| 2476, Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,5 |
| 12455,,19 |
| 10628,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 153, |
| ,7 |
| 5015,Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.,24 |
| 7852,Evaluation for bariatric surgery.,2 |
| 10653,A 23-year-old white female presents with complaint of allergies.,0 |
| 8999,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.,13 |
| 3168,,3 |
| 1057, Worrisome skin lesion. A punch biopsy of the worrisome skin lesion was obtained. Lesion was removed.,38 |
| 6980,Itchy red rash on feet - Tinea Pedis,31 |
| 9419,,19 |
| 9713,A sample note on Rheumatoid Arthritis,34 |
| 1251, Repair of ruptured globe involving posterior sclera - Sample/Template. ,38 |
| 5446,Right lower pole renal stone and possibly infected stent. Cysto stent removal.,21 |
| 11106,Patient presents for therapy of suspected rheumatoid arthritis.,34 |
| 8735,Evaluation for bariatric surgery.,2 |
| 1643,,14 |
| 3157,,20 |
| 624,,5 |
| 3781, A 9-month well-child check.,5 |
| 954, The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. ,5 |
| 11145,A sample note on Rheumatoid Arthritis,34 |
| 5296,,10 |
| 9038,,9 |
| 5018,,35 |
| 3303,,33 |
| 6120,,31 |
| 10714,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 4304,,12 |
| 4115,,39 |
| 7083,Patient being referred for evaluation of glaucoma.,20 |
| 6023,,28 |
| 6387,,26 |
| 3674,,5 |
| 9739,,34 |
| 12226,,19 |
| 3112, Ligament reconstruction and tendon interposition arthroplasty of right wrist.,38 |
| 11581,,1 |
| 9131,Consult for laparoscopic gastric bypass.,2 |
| 9537,,0 |
| 8251,,8 |
| 5667,,19 |
| 7029,Diagnosis of benign rolandic epilepsy.,20 |
| 4299,Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.,11 |
| 5620,The client is being discharged for continued hemodialysis and rehab.,21 |
| 11856,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 |
| 3516,,38 |
| 2777, Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,27 |
| 5702,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 |
| 7572,,19 |
| 4276,Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.,8 |
| 5316,,25 |
| 2013,,35 |
| 9874,Dietary consultation for diabetes during pregnancy.,9 |
| 3481,,5 |
| 4286,,35 |
| 5278,The client underwent a total vaginal hysterectomy.,10 |
| 13, Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,23 |
| 9308,,37 |
| 11970,,19 |
| 991,,36 |
| 2709,,38 |
| 10129,Patient referred for narrow angles and possible associated glaucoma.,20 |
| 5645,,23 |
| 6946,Caudal epidural steroid injection,28 |
| 6885,,25 |
| 11907,Occupational medicine consult with questions-answers and records review.,18 |
| 5380,,10 |
| 1937,,24 |
| 9792,,17 |
| 9730,,34 |
| 8445,,0 |
| 1216,,38 |
| 6655,,16 |
| 5904,,10 |
| 11645,Dietary consultation for diabetes during pregnancy.,9 |
| 10051,The case is being referred for evaluation of diabetic retinopathy.,20 |
| 11043,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 246, Insertion of central venous line and arterial line and transesophageal echocardiography probe.,3 |
| 6455,,2 |
| 12411,Dietary consultation for gestational diabetes.,9 |
| 3380,,28 |
| 7603,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 8803,,4 |
| 2778, OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.,38 |
| 3093,,38 |
| 4347,,21 |
| 3653, Colonoscopy to screen for colon cancer,38 |
| 11068,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 |
| 4369,,14 |
| 7873,Woman with a history of macular degeneration. PDT therapy. Some vision therapy. Complete refractive work-up.,20 |
| 9107,,19 |
| 143, Sample progress note - Gen Med.,15 |
| 10269,Consult for laparoscopic gastric bypass.,2 |
| 4143,,10 |
| 9358,,0 |
| 4220,External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.,24 |
| 6842,Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.,29 |
| 7041,,29 |
| 4704,Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 |
| 360,,14 |
| 7826,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 9321,,37 |
| 4071,Primary low-transverse cesarean section.,24 |
| 12441,A sample note on Rheumatoid Arthritis,34 |
| 2739, Upper endoscopy with foreign body removal (Penny in proximal esophagus).,38 |
| 3874, Hyperfractionation. This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. ,16 |
| 464,,39 |
| 12618,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 7062,,31 |
| 1728, Patient in with mom for possible ear infection.,5 |
| 6526,This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.,12 |
| 3465,,38 |
| 6805,,28 |
| 9848,A 23-year-old white female presents with complaint of allergies.,0 |
| 641, Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.,27 |
| 12629,,34 |
| 4234,,0 |
| 8261,,2 |
| 3320, Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.,27 |
| 9497,,19 |
| 11438,,37 |
| 7924,,30 |
| 3118,,14 |
| 4346,,21 |
| 11130,,17 |
| 2528, Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.,12 |
| 5441,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 |
| 6979,Itchy red rash on feet - Tinea Pedis,31 |
| 4444,4-day-old with hyperbilirubinemia and heart murmur.,12 |
| 4994,,23 |
| 2721,,39 |
| 1158, Follow up update on patient with left carotid angioplasty and stent placement.,3 |
| 295, Left temporal craniotomy and removal of brain tumor.,22 |
| 7809,Follow up update on case with left carotid angioplasty and stent placement.,20 |
| 9385,,1 |
| 6818,Coccygeal injection,28 |
| 345,,35 |
| 6729,Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,23 |
| 1570, An example/template for a routine normal male physical exam.,15 |
| 11477,,34 |
| 14,,24 |
| 5312,Bilateral myringotomies with insertion of Santa Barbara T-tube.,11 |
| 3557, Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.,38 |
| 7085,,25 |
| 11469,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.,18 |
| 5953,,12 |
| 3390,,31 |
| 6371,Migraine headache - The case was seen in the urgent care.,12 |
| 3486, Right nodular malignant mesothelioma.,16 |
| 11948,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 3828,,22 |
| 12266,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 5231,,36 |
| 4818,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 2794, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,38 |
| 12219,,19 |
| 6312,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 9444,,19 |
| 4826,A 31-year-old white female admitted to the hospital with pelvic discomfort and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.,10 |
| 10071,,36 |
| 8794,,18 |
| 10110,Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.,36 |
| 7809,Follow up update on case with left carotid angioplasty and stent placement.,20 |
| 10455,Elevated cholesterol and is on medication to lower it.,9 |
| 12532,,0 |
| 8356,Qualified medical evaluation report of a case with back pain.,4 |
| 4127,,35 |
| 11890,,9 |
| 4171,Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.,10 |
| 9433,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 7703,,7 |
| 12180,A 23-year-old white female presents with complaint of allergies.,0 |
| 12508,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 11229,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 8690,Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.,36 |
| 7891,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 |
| 4113,,39 |
| 1246, A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. ,24 |
| 7686,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 |
| 10995,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 1241,,14 |
| 6169,,6 |
| 6155,Preop evaluation regarding gastric bypass surgery.,2 |
| 12110,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 4194,Procedure note on Keller Bunionectomy,31 |
| 9162,Patient discharged after laparoscopic Roux-en-Y gastric bypass.,2 |
| 4931,,11 |
| 12186,A 23-year-old white female presents with complaint of allergies.,0 |
| 1229, Patient with a past medical history of hypertension for 15 years.,5 |
| 2239, Left direct and indirect inguinal hernia. Repair of left inguinal hernia with Prolene mesh. The patient was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,39 |
| 6888,Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.,8 |
| 3053,,30 |
| 4995,,21 |
| 11974,Occupational medicine consult with questions-answers.,18 |
| 5810,Cadaveric renal transplant to right pelvis - endstage renal disease.,21 |
| 4096,,28 |
| 6710,Qualified medical evaluation report of a case with back pain.,18 |
| 2024, Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.,35 |
| 510,,35 |
| 7944,A simple note on Acne Vulgaris.,8 |
| 10016,Follow up update on case with left carotid angioplasty and stent placement.,20 |
| 990, Occupational medicine consult with questions-answers.,18 |
| 1868, |
| ,38 |
| 5878,Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,16 |
| 10457,,13 |
| 4592,Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,26 |
| 12229,Mother states he has been wheezing and coughing.,0 |
| 6013,MRI report Cervical Spine (Chiropractic Specific),4 |
| 9703,A sample note on Rheumatoid Arthritis,34 |
| 9439,,19 |
| 11273,Work restrictions and disability evaluation,18 |
| 9511,Autopsy of a white female who died of acute combined drug intoxication.,1 |
| 8363,Elevated cholesterol and is on medication to lower it.,9 |
| 4655,A 47-year-old female with a posttraumatic AV in the right femoral head.,10 |
| 12179,A 23-year-old white female presents with complaint of allergies.,0 |
| 968, A 60-year-old female presents today for care of painful calluses and benign lesions.,31 |
| 4954,Vitrectomy under local anesthesia.,26 |
| 10513,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 691, Frontal and lateral views of the hip and pelvis.,29 |
| 9743,,34 |
| 7863,,36 |
| 5727,Common CT Neck template.,11 |
| 8098,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 |
| 10511,Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with determination of CVA with right hemiparesis.,30 |
| 1132, Ultrasound OB - followup for fetal growth.,24 |
| 1090, Right pleural effusion and suspected malignant mesothelioma.,38 |
| 7817,,2 |
| 10679,Dietary consultation for gestational diabetes.,9 |
| 8318,Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.,2 |
| 664, Transforaminal epidural steroid block with fluoroscopy.,28 |
| 8720,A 23-year-old white female presents with complaint of allergies.,0 |
| 9965,Letter on evaluation regarding extraction of mandibular left second molar tooth #18.,20 |
| 7020,Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury,18 |
| 4139,,12 |
| 6114,A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,12 |
| 1400,,38 |
| 1200, Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. ,38 |
| 5823,Underwent tonsillectomy and adenoidectomy two weeks ago.,25 |
| 10106,,30 |
| 1239,,38 |
| 10606,Pain management for post-laminectomy low back syndrome and radiculopathy.,4 |
| 12218,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 6732,Phacoemulsification with posterior chamber intraocular lens insertion.,26 |
| 1230, Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation,27 |
| 10172,Consultation for left foot pain.,4 |
| 6811,,8 |
| 3708,,27 |
| 12343,Work restrictions and disability evaluation,4 |
| 9085,,19 |
| 12166,,1 |
| 6344,Standard hypogastric plexus block procedure note.,28 |
| 2934, Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.,28 |
| 11265,Normal awake and drowsy (stage I sleep) EEG for patient's age.,36 |
| 7378,"Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.",30 |
| 3120, Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,38 |
| 4429,Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.,33 |
| 9245,"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 |
| 2171," Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. ",3 |
| 59, Closure of gastrostomy placed due to feeding difficulties. ,14 |
| 5783,Chiropractic IME with answers to questions from Insurance Company.,18 |
| 6058,Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.,25 |
| 5021,Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.,35 |
| 1463, Insertion of transvenous pacemaker for tachybrady syndrome,3 |
| 3522," Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.",5 |
| 6919,"Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming determination of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.",12 |
| 9117,Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.,2 |
| 4643,"A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.",29 |
| 604, Collar Tubes technique,38 |
| 5894,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.,8 |
| 12620,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 |
| 5650,"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.",31 |
| 8028,"The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.",9 |
| 10064,"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 |
| 2008," Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.",35 |
| 6172,"A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.",10 |
| 2270, Occupational medicine consult with questions-answers and records review.,5 |
| 2105, Esophagogastroduodenoscopy with biopsy.,38 |
| 8314,"Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.",0 |
| 10639,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",2 |
| 10946,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 11615,A 23-year-old white female presents with complaint of allergies.,0 |
| 4777,"Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm. Right ureteropelvic junction calculus.",39 |
| 5485,Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.,1 |
| 7468,"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 |
| 5997,Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.,16 |
| 9548,"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 |
| 11159,A sample note on Rheumatoid Arthritis,34 |
| 6878,A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,12 |
| 628," Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.",15 |
| 10396,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 12630,"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 |
| 4001,"Bilateral Mammogram, (abnormal) additional views requested",33 |
| 12553,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 9471,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 10022,"Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.",6 |
| 4948,Follow up update on case with left carotid angioplasty and stent placement.,20 |
| 11894,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17. |
| |
| 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. |
| |
| |
| |
| |
| |
| |
| |
| Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. |
| Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 |
| |
| |
| Stab wound, left posterolateral chest. Closure of stab wound. |
| Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. |
| |
| Fever, otitis media, and possible sepsis. |
| |
| |
| |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 6201,A well-child check with concern of some spitting up quite a bit.,29 |
| 11991,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 |
| 9305,"Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. |
| The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. |
| |
| Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.",26 |
| 5701,A 5-month-old boy brought by his parents because of 2 days of cough.,29 |
| 9172,"Status post brain tumor with removal. The case 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 |
| 11909,Occupational medicine consult with questions-answers and records review.,18 |
| 9008,A sample note on Rheumatoid Arthritis,34 |
| 4976,"A white female who presents for complete physical, Pap and breast exam.",24 |
| 10343,The client has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,36 |
| 1857, An example of a physical exam,5 |
| 10095,Chiropractic IME with old files review. Detailed Thoracic Spine Examination.,18 |
| 930, Pulmonary function test. Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy.,3 |
| 9915,Work restrictions and disability evaluation,4 |
| 5180,"Left flank pain, ureteral stone.",39 |
| 8069,"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.",19 |
| 10144,Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,20 |
| 10641,"First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. |
| |
| Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy. |
| |
| Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.",37 |
| 12477,"Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.",9 |
| 10098,Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,13 |
| 4839,Nephrology office visit for followup of microscopic hematuria.,21 |
| 8123,"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 |
| 6611,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.,18 |
| 9025,Cognitive linguistic impairment secondary to stroke. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 6832,,30 |
| 5414,This case was seen in clinic for a school physical.,29 |
| 1049,,38 |
| 3836,,3 |
| 7347,Work restrictions and disability evaluation,4 |
| 3671,,38 |
| 7140,,37 |
| 8064,Significant discomfort in left lower jaw.,7 |
| 9285,,9 |
| 3422, Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,22 |
| 1269,,24 |
| 5204,Normal vasectomy,39 |
| 12568,,19 |
| 7584,Is it BNP or BMP?,19 |
| 3821, ,38 |
| 4746,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 268,,5 |
| 7499,Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.,17 |
| 1968, Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,5 |
| 12504,,37 |
| 8123,,6 |
| 10858,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 |
| 7813,,36 |
| 12248,Autopsy - Homicide - Blunt force cranial trauma,1 |
| 5733,,6 |
| 5744,Mother states he has been wheezing and coughing.,29 |
| 6717,Tonsillectomy and adenoidectomy and Left superficial nasal cauterization. Recurrent tonsillitis. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. Residual adenoid hypertrophy and recurrent epistaxis.,11 |
| 5716,Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.,29 |
| 12437,A female for a complete physical and follow up on asthma with allergic rhinitis.,0 |
| 9082,,19 |
| 12570,,19 |
| 4302,,12 |
| 8151,Consultation for wrist pain.,4 |
| 4865,,26 |
| 6219,Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique.,28 |
| 496, Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.,31 |
| 8125,,6 |
| 10783,Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.,37 |
| 10596,Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.,2 |
| 7091,"Counting calorie points, exercising pretty regularly, seems to be doing well",9 |
| 9957,"Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. |
| Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis. |
| A nurse with a history of breast cancer enrolled is clinical trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. |
| |
| |
| Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. |
| |
| Global aphasia. The case is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.",37 |
| 9611,"Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. |
| |
| Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank. |
| |
| |
| Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo. |
| Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique. |
| |
| Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".",19 |
| 6273,An example/template for a routine normal male physical exam.,25 |
| 1442," Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.",27 |
| 1979," Fever, otitis media, and possible sepsis.",11 |
| 3414," Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.",38 |
| 10029,"Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris",8 |
| 2722, MRI left shoulder.,33 |
| 7619,Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.,17 |
| 5812,Cadaveric renal transplant to right pelvis - endstage renal disease.,21 |
| 9313,"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 |
| 5136,A 23-year-old white female presents with complaint of allergies.,35 |
| 5806,"Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.",25 |
| 1029, Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak. Diffuse intestinal and mesenteric lymphangiectasia. ,38 |
| 4603,Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.,23 |
| 7893,Hand dermatitis.,8 |
| 12650,Patient presents for care of suspected rheumatoid arthritis.,34 |
| 4272,"Management of end-stage renal disease (ESRD), the case on chronic hemodialysis, being admitted for chest pain.",21 |
| 7902,"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 |
| 2913," Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.",38 |
| 233," Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.",24 |
| 10088,"Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.",4 |
| 9265,Dietary consultation for carbohydrate counting for type I diabetes.,9 |
| 5556,Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.,26 |
| 12075,"Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.",0 |
| 8418,Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.,13 |
| 6763,"Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.",21 |
| 4309,Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.,22 |
| 3786, Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.,14 |
| 3594," 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.",5 |
| 6647,A 19-year-old right-handed male injured in a motor vehicle accident.,20 |
| 493, 2-D Echocardiogram,33 |
| 302," 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 pain that radiates from her back into her legs. She has had no associated weakness.",33 |
| 7599,Mother states he has been wheezing and coughing.,0 |
| 3951, Patient presents for treatment of suspected rheumatoid arthritis.,34 |
| 1768," Toenails are discolored, thickened, and painful - Onychomycosis",31 |
| 11331,The client 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 |
| 9081,,19 |
| 5192,,31 |
| 4458,Sample Radiology report of knee (growth arrest lines).,33 |
| 8294,Diagnosis of benign rolandic epilepsy.,20 |
| 11878,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 1787,,3 |
| 3525,,14 |
| 11916,,37 |
| 5660,1-year well child check.,29 |
| 10210,MRI report Cervical Spine (Chiropractic Specific),4 |
| 3590, CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization.,33 |
| 683, Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion.,38 |
| 9254,The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,19 |
| 4956,,36 |
| 3286,,38 |
| 8098,The case is status post C3-C4 anterior cervical discectomy and fusion.,30 |
| 7124,The client was referred due to a recent admission for pseudoseizures.,32 |
| 8207,Chiropractic Evaluation for neck and low back ache following a car accident.,4 |
| 932,,38 |
| 9393,,1 |
| 7057,,26 |
| 7002,,12 |
| 12346,,9 |
| 9060,Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.,13 |
| 5159,A 3-year-old abrupt onset of cough and increased work of breathing.,29 |
| 2083, Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.,38 |
| 8124,,6 |
| 9465,Mother states he has been wheezing and coughing.,0 |
| 10427,,13 |
| 6730,Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,23 |
| 6612,,21 |
| 11850,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 |
| 11875,A lady with symptoms consistent with possible oligoarticular arthritis of her knees.,34 |
| 7795,Chiropractic IME with answers to questions from Insurance Company.,4 |
| 22, A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. ,5 |
| 8673,,2 |
| 3881,,32 |
| 11599,Hospice visit for 77-year-old gentleman with advanced colon cancer.,17 |
| 11218,,1 |
| 6681,,31 |
| 517,,27 |
| 4494,Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,12 |
| 2379, Acne with folliculitis.,35 |
| 3185,,30 |
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