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{ "text": "PREOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:, In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 3229 }

{ "text": "PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec. She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:, Negative for heart, lungs, GI, GU, cardiac, or neurologic. Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile. Vital Signs are stable. HEENT: EOMI. PERRLA. Neck is soft and supple. Lungs clear to auscultation. She is mildly tender in the abdomen in the right upper quadrant. No rebound. Abdomen is otherwise soft. Positive bowel sounds. Extremities are nonedematous. Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications. She understands and we will proceed with the surgery in the near future.," }

[ { "label": " Gastroenterology", "score": 1 } ]

{ "text_length": 1644 }

{ "text": "CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing \"like it was compressed from the top down with a black sheet coming down\". The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative. A copy is in his clinic chart.,PAST MEDICAL HISTORY: ,As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs: BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds. He denies any pain.,General: This is a pleasant white male in no acute distress.,HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness.,Neck: Supple.,Chest: Clear to auscultation.,Heart: There are no bruits present.,Extremities: Extremities are warm and dry. Distal pulses are full. There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS: He is alert and oriented to person, place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good.,CRANIAL NERVES: Cranial nerves II through XII are intact. VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR: He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY: He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION: There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms.,GAIT: Upon arising, he has a normal step, stride, and toe, heel. He has difficulty with tandem and tends to fall to the left.,REFLEXES: 2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion, stenosis, and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1. We will get a CT angiogram of the cerebral vessels.,2. Continue Plavix.,3. Obtain copies of the workup done at the outside hospital.,4. We will follow the lumbar stenosis for the time being. No further workup is planned." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 5919 }

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

[ { "label": " General Medicine", "score": 1 } ]

{ "text_length": 1666 }

{ "text": "PROCEDURES:,1. Release of ventral chordee.,2. Circumcision.,3. Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding. He is here electively for surgical correction.,DESCRIPTION OF PROCEDURE: , The patient was brought back into operating room 35. After successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,A holding stitch was placed in the glans penis. At this point, we probed both urethral meatus. Using the Crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus. At this point, we cannulated this with a 6-French hypospadias catheter. We attempted to cannulate the dorsal opening, however, we were unsuccessful. We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication. At this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors. We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,At this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee. Once all the chordee had been adequately released, we turned our attention to the circumcision. Excessive dorsal foreskin was removed from the skin and glans. Mucosal cuts were reapproximated with interrupted 5-0 chromic suture. Dermabond was placed over this and bacitracin was placed on this once dry. This ended the procedure. ,DRAINS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,URINE OUTPUT: ,Unrecorded.,COMPLICATIONS: , None apparent.,DISPOSITION: ,The patient will now go under the care of Dr. XYZ, Plastic Surgery, for excision of scalp hemangioma." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 2016 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:, Less than 10 cc.,INDICATIONS: ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time. The patient 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.,PROCEDURE:, The patient was consented and seen in the preoperative suite. She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation. She was prepped and draped in the normal sterile fashion. Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine. A bimanual exam was done, was performed by Dr. X and Dr. Z. The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage. The cervix and vagina were grossly normal with no obvious masses or deformities. A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm. The cervix was sterilely dilated with Hank dilator and then Hagar dilator. At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously. The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus. Under direct visualization, the ostia were within normal limits. The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps. The hyperplastic tissue did not appear to have calcification or other abnormalities. There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature. The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance. Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting. The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation. A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac. There was a normal consistency of the cervix and the normal step-off. The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum. The cervix was found to be hemostatic. The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room. The patient will be sent home once stable from anesthesia. She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings. The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin. The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks. The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 3628 }

{ "text": "XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side. His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration. They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially. I think he should stay on MiraLax for management of his bowels. I would also suggest that he be referred to Pediatric Gastroenterology for evaluation. If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic. If you have any questions, please feel free to contact me. ,Sincerely yours," }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 1455 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 4635 }

{ "text": "PROCEDURE PERFORMED:, Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion. Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:, None. The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 1252 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:, The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery. The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth. After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1. Methadone.,2. Beta-blocker.,3. Xanax.,4. Norco.,5. Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present. The patient was prepped and draped in sterile fashion. Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible. Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered. Extraction sites were thoroughly curettaged and irrigated. Bony undercuts were removed then smoothed with rongeurs and bone saw. After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures. Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions. Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged. Wound was closed in continuous fashion 3-0 chromic. After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control. Total of 8 mL were used. Throat pack was subsequently removed. Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery. The patient would be placed in 23-hour observation." }

[ { "label": " Dentistry", "score": 1 } ]

{ "text_length": 2848 }

{ "text": "IDENTIFYING DATA: , The patient 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. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a \"panic attack leading to the car wreck\" and denies that any of his behavior was suicidal in nature responding, \"I was just trying to scare my mother.\",CHIEF COMPLAINT: , The patient does say, \"I screwed up my whole life and wrecked my car.\" The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes \"allergy\" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 3591 }

{ "text": "PREOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis. She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum. Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision. A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator. The bony deflection was removed using Jansen-Middleton forceps. The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest. The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side. Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps. Approximately 10 cc total was used. The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better. The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site. The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection. Bright mucosal disease and small polypoid accumulations were noted through the sinuses also. The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy. The mucosal polypoid accumulations were cleared using the Richards essential shaver. The turbinate was partially resected from mucosally but with good shape to it. It was not desirable to remove it in its entirety. Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used. The polyps were removed. The Richards essential shaver was used to allow better exposure of the uncinate process. The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also. The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection. The inferior turbinates showed mucosal disease, polypoid accumulations, and changes. These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus. A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions. The patient tolerated the procedure well and returned to the recovery room in stable condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 5260 }

{ "text": "PRE-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2. Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:, Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:, The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 5210 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed.,IMPRESSION: ,1. Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time. We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2. Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate. The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy. However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed. The patient not to use them at the same time. Will call if any other concern. In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy. He declined scheduling this at this time. All questions answered." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 2032 }

{ "text": "EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS: ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal Doppler blood flow. The left epididymis has an unremarkable appearance. There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm. The epididymis has normal appearance. There is a trace hydrocele. No intratesticular masses or torsion is identified. There is no significant scrotal wall thickening.,IMPRESSION: ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 741 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED: ,1. Pelvic laparotomy.,2. Lysis of pelvic adhesions.,3. Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS: ,There was a transabdominal mass palpable in the lower left quadrant. An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE: ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped. A low transverse incision was made down to and through to the rectus sheath. The rectus sheath was put laterally. The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures. The rectus muscle was then split transversally and the peritoneum was split transversally as well. The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass. The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament. The infundibulopelvic ligament was isolated, entered via blunt dissection. A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place. Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place. Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion. Irrigation was used. Minimal blood loss at the time of surgery was noted. Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum. Instrument, needle, and sponge counts were called for and found to be correct. The peritoneum was closed with #0 Vicryl continuous running locking suture. The rectus sheath was closed with #0 Vicryl continuous running locking suture. A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples. Final instrument needle counts were called for and found to be correct. The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 2662 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 6701 }

{ "text": "DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS: , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:, Urology.,PROCEDURES DURING THIS HOSPITALIZATION:, On MM/DD/YYYY, ,1. Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2. Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY. He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement. Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The procedure was without complications. The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation. He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. We advanced him as tolerated to a regular health select diet by postoperative day #4. His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used. He was then switched over to p.o. pain medicines and has required very little for adequate pain control. By postoperative date #2, the patient had been out of bed and ambulating in the hallways. The patient's only problem was with some mild diarrhea on postoperative days #3 and 4. This was thought to be a result of his right hemicolectomy. A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea. His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints. He had been afebrile throughout his hospitalization and his vital signs were stable. Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. His midline incision is clean, dry, and intact and staples are in place. He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE: ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1. Multivitamins daily.,2. Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3. Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4. Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5. Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:, The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time." }

[ { "label": " General Medicine", "score": 1 } ]

{ "text_length": 3928 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,OPERATION PERFORMED:, OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:, Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy. The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain. Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow. After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 895 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,DESCRIPTION OF PROCEDURE:, Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 1619 }

{ "text": "PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 1511 }

{ "text": "PROCEDURE CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's mom. The patient was brought to minor procedures and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation. Approximately 4 mL of 5% phenol was injected in this location bilaterally. Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. After injections were performed, bilateral short leg fiberglass casts were applied. The patient tolerated the procedure well and no complications were encountered." }

[ { "label": " Neurosurgery", "score": 1 } ]

{ "text_length": 1431 }

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

[ { "label": " Allergy / Immunology", "score": 1 } ]

{ "text_length": 1331 }

{ "text": "2-D M-MODE: , ,1. Left atrial enlargement with left atrial diameter of 4.7 cm.,2. Normal size right and left ventricle.,3. Normal LV systolic function with left ventricular ejection fraction of 51%.,4. Normal LV diastolic function.,5. No pericardial effusion.,6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7. PA systolic pressure is 36 mmHg.,DOPPLER: , ,1. Mild mitral and tricuspid regurgitation.,2. Trace aortic and pulmonary regurgitation." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 495 }

{ "text": "SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center. The aortic stenosis was secondary to a congenital bicuspid valve, by her description. She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition. She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days. Last night, she had a prolonged episode for which she contacted EMS. Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day. She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively. She states that she has been taking her aspirin at 325 mg q.a.m. She remains on Zyrtec 10 mg q.a.m. Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS: Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60. The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL: She is alert and in no apparent distress.,HEENT: Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST: Lungs are clear bilaterally to auscultation. The incision is well healed and without evidence of significant cellulitis.,HEART: Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub. There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN: Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES: Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC: Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function. Gait and station were not tested.,MENTAL STATUS: Shows the patient to be alert, coherent with full capacity for decision making.,BACK: Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000. INR 1.0. Electrolytes are normal with exception potassium 3.3. GFR is decreased at 50 with creatinine of 1.1. Glucose was 119. Magnesium was 2.3. Phosphorus 3.8. Calcium was slightly low at 7.8. The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge. Troponin is negative x2 from 2100 and repeat at 07:32. This morning, her BNP was 163 at admission. Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion. Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds. Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient. I contacted Dr. Varner and we reviewed the patient's managed to this point. All combined impression is that the patient was likely to not have had actual ventricular tachycardia. This is based on her EP study from October showing her to be non-inducible. In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease. What is most likely that the patient has postoperative atrial fibrillation. Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely. At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period. I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated. Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1. Atrial fibrillation with rapid ventricular response.,2. Wolff-Parkinson White Syndrome.,3. Recent aortic valve replacement with bioprosthetic Medtronic valve.,4. Hyperlipidemia." }

[ { "label": " SOAP / Chart / Progress Notes", "score": 1 } ]

{ "text_length": 4970 }

{ "text": "EXAM:, Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are grossly normal. LV wall thickness and wall motion appeared normal. LV ejection fraction is estimated at 65%. Aortic root and cardiac valves appeared normal. No evidence of pericardial effusion. No evidence of intracardiac mass or thrombus. Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. There is mild tricuspid regurgitation. Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1. LV Ejection fraction, estimated at 65%.,2. Mild left atrial enlargement.,3. Mild tricuspid regurgitation.,4. Mildly elevated pulmonary systolic pressure." }

[ { "label": " Radiology", "score": 1 } ]

{ "text_length": 964 }

{ "text": "Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation." }

[ { "label": " Neurology", "score": 1 } ]

{ "text_length": 1139 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE: ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient 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. The fluid size tends to fluctuate with time but has been relatively persistent for the past year. I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options. All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS: ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum. We probably drained around 10 to 15 mL of fluid from the hydrocele sac. The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed. There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic. A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair. After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine. A curvilinear incision was made low in the left inguinal area along one of prominent skin folds. Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures. The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents. The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl. After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures. Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure. The patient tolerated the operation well. He was awakened and taken to the recovery room in good condition. Blood loss was minimal. No specimen was submitted.," }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 2883 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right spermatocele.,POSTOPERATIVE DIAGNOSIS: ,Right spermatocele.,OPERATIONS PERFORMED:,1. Right spermatocelectomy.,2. Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: ,The patient is a 77-year-old male who comes to the office with a large right spermatocele. The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove. Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed. The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down. The patient was told about the risk of recurrence of spermatocele. The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion. A midline scrotal incision was made measuring about 2 cm in size. The incision was carried through the dartos through the scrotal sac and the spermatocele was identified. All the layers of the spermatocele were removed. Clear layer was visualized, was taken all the way up to the base, the base was tied. Entire spermatocele sac was removed. After removing the entire spermatocele sac, hemostasis was obtained. The testicle was not in normal orientation. The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle. The testicle was placed in a normal orientation. Careful attention was drawn not to twist the cord. Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations. Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period. The dartos was closed using 2-0 Vicryl in running locking fashion. There was excellent hemostasis. The skin was closed using 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well. The patient was brought to the recovery room in stable condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 2416 }

{ "text": "COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:, Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:, The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 5109 }

{ "text": "HISTORY OF PRESENT ILLNESS:, Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp and vital signs are all within normal limits.,GENERAL: In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT: Head is normocephalic and atraumatic. The face shows no edema. The tongue is not swollen and the airway is widely patent.,NECK: No stridor.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,EXTREMITIES: Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals. There was some slight edema of the fourth digit, on which he still is wearing his wedding band. The right hand shows no reaction. The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty. Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting. I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction. I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone. I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction. If he is not improved in the next four days, follow up with his PCP for a re-exam." }

[ { "label": " General Medicine", "score": 1 } ]

{ "text_length": 2770 }

{ "text": "REASON FOR CONSULTATION: ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. He noticed a small dark spot. He did not remember having had any injuries to that area specifically no puncture wounds. He had not been doing any outdoor works or activities. No history of working outdoors, has not been to the beach or to the lake, has not been out of town. His swelling progressed so he went to see Dr. X 4 days ago. The area was debrided in the office and he was placed on Keflex. It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies. His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening. Ancef and Cipro were prescribed today. He denies any fever, chills, red streaks, lymphadenitis. He had a tetanus shot in 2002 most recently. He had childhood asthma. He uses alcohol socially. He works full time. He is an electrician.,ALLERGIES:, ACCUTANE.,PHYSICAL EXAMINATION,GENERAL: Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS: His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT: Mouth unremarkable.,NECK: Supple.,LUNGS: Clear.,HEART: Regular rate rhythm. No murmur or gallop.,ABDOMEN: Soft and nontender.,EXTREMITIES: Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema. There is bloodied blister around it. The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema. There is some mild intertrigo between the fourth and fifth left toes. Palpable pedal pulses. Leg unremarkable. No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110. Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal. PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION: ,Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour. Cultures, Gram stain, fungal cultures, and smear to be obtained. I have changed his antibiotic to vancomycin plus Maxipime. He is currently on tetanus immunizations so no need for booster at this time.," }

[ { "label": " Podiatry", "score": 1 } ]

{ "text_length": 2767 }

{ "text": "EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.," }

[ { "label": " Radiology", "score": 1 } ]

{ "text_length": 2471 }

{ "text": "CHIEF COMPLAINT: , \"Bloody bump on penis.\",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half. He states that it has never bled before. It has never caused him any pain or has never been itchy. The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years. He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice. The patient does state that last night he was \"trying to get some,\" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis. The patient said that there is a large amount of blood from this injury. This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding. The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed. The patient denies any drainage or discharge from his penis. He denies fevers or chills recently. He also denies nausea or vomiting. The patient has not had any discharge from his penis. He has not had any other skin lesions on his penis that are new to him. He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years. The patient has never had these checked out. He denies fevers, chills, or night sweats. He denies unintentional weight gain or loss. He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY: ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage. He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION: ,GENERAL: This is an African-American male who appears his stated age of 29 years. He is well nourished, well developed, in no acute distress. The patient is pleasant. He is sitting on a Emergency Department gurney.,VITAL SIGNS: Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART: Regular rate and rhythm. Clear S1, S2. No murmur, rub, or gallop is appreciated.,LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.,ABDOMEN: Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY: The patient's external genitalia is markedly abnormal. There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus. This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter. The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well. There are no open lesions at this point. There is a small tear of the skin where the mass attaches to the glans near the urethral meatus. Bleeding is currently stanch, and there is no sign of secondary infection at this time. Bilateral testicles are descended and normal without pain or mass bilaterally. There is no inguinal adenopathy.,EXTREMITIES: No edema.,SKIN: Warm, dry, and intact. No rash or lesion.,DIAGNOSTIC STUDIES: ,Non-emergency department courses. It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass. The patient does have a large pedunculated penile mass. He will be referred to the urologist who is on-call today. The patient will need this mass excised and biopsied. The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.," }

[ { "label": " Emergency Room Reports", "score": 1 } ]

{ "text_length": 4143 }

{ "text": "HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month.,3. He had an appendectomy in the 1940s.,4. He had an ankle resection in 1975.,SOCIAL HISTORY: ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:, He has no medication or food allergies.,REVIEW OF SYSTEMS:, Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair. His pain score was 0.,APPEARANCE: No acute distress. He is pleasant and well-groomed.,HEENT: Atraumatic, normocephalic. No carotid bruits appreciated.,LUNGS: There were few coarse crackles in both lung bases.,CARDIOVASCULAR: Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs. The pulse was regular and of normal volume.,ABDOMEN: Soft with no masses and normal bowel sounds. There were no carotid bruits.,EXTREMITIES: No contractures appreciated.,NEUROLOGICAL EXAM:,MSE: His orientation, language, calculations, 100-7 tests were all normal. There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES: Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations. His palatal movement was normal and gag reflex was normal.,MOTOR: Strength was decreased in all muscle groups as follows: Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4. Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1. There was atrophy in both hands and general atrophy of the lower limb muscles. The feet were both cold and showed dystrophic features. Fasciculations were present mainly in the hands. There was evidence of dysmetria and past pointing in the left hand.,REFLEXES: Reflexes were 0 in all sites in the arms and legs. The jaw reflex was 2+. Vibration was severely decreased at the elbow and wrist and was absent in the fingers. Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee. Joint position sense was absent in the toes and severely decreased in the fingers. Pin perception was absent in the feet and was decreased to the upper thighs. Pin was decreased or absent in the fingers and decreased above the elbows. The same distribution of sensory loss was found with monofilament testing.,COORDINATION: Coordination was barely normal in the right hand. Rapid alternating movements were decreased in the left hand greater than the right hand. The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports. There were extensive patient reports, all of which were reviewed. A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate. An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis. A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis. The posterior circulation showed a slightly dominant right vertebral artery with no stenosis. There was no significant stenosis, but there was minor extracranial stenosis noted. An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration. There was also no significant sinusitis or mastoiditis. This was an essentially normal brain MRI. A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal. An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1. The glucose was 86. TSH performed in January 2009 was 1.57, which is within the normal range. Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal. A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT. The ECG was non-diagnostic. There was normal regional wall motion of the left ventricle. The left ventricular ejection fraction was 68%, which is within the normal range for males. A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5. At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis. There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4. An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION: ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings. He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities. His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia. According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008. As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy. There was no involvement of the tongue on EMG. The laboratory testing as indicated below failed to show a specific cause for the neuropathy. We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic. This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease. In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents. The patient did not receive any of these. It may also be seen as part of a paraneoplastic syndrome. Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking. We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation. The verbal reports of these possibly did not show any evidence of a cancer. We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm. The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm. This showed evidence of severe axonal loss. There was no evidence of a vasculitis. The vessels did show some mild intimal changes that would be consistent with atherosclerosis. There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections. The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping. Again, there was no evidence of inflammation or vasculitis. Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy. Specifically, there is no history of HIV exposure. We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis. At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed. I have discussed these issues at length with the patient and with his son. We also addressed whether or not there might be a previously undiagnosed inherited neuropathy. I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2. However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1. Nerve conduction and EMG will be performed today. The results were indicated above.,2. The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12. These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7. The B12 was greater than 2000. The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative. The B12 level was greater than 2000. Liver function tests were normal. The glucose was 90. ESR was 10. Hemoglobin A1c was 5.5.,3. A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4. CT of chest, abdomen and pelvis.,5. Whole body gallium scan for evidence of an underlying neoplasm.,6. The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7. We have not made any changes to his medication. He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day. Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8. Followup will be as determined by the family." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 15216 }

{ "text": "CHIEF COMPLAINT:, The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:, The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pain before her period starts. Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks. She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed. The cramping is worse. She said her flow has increased. She has to change her pad every half to one hour and uses a super tampon sometimes. She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad. She also notes that her headaches have been worsening a little bit. She has had quite a bit of stress. She had a headache on Wednesday again after having had one on the weekend. She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them. She avoids caffeine. She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:, None.,SOCIAL HISTORY:, She is a nonsmoker. She is not sexually active.,PAST MEDICAL HISTORY:, She has had no surgery or chronic illnesses.,FAMILY HISTORY:, Mother has hypertension, depression. Father has had renal cysts and sometimes some stomach problems. Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:, Patient denies headache or trauma. No blurred or double vision. Hearing is fine, no tinnitus or infection. Infrequent sore throat, no hoarseness or cough.,HEENT: See HPI.,Neck: No stiffness, pain or swelling.,Respiratory: No shortness of breath, cough or hemoptysis. She is a nonsmoker.,Cardiovascular: No chest pain, ankle edema, palpitations or hypertension.,GI: No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU: No dysuria, frequency, urgency or stress incontinence.,Locomotor: No weakness, joint pain, tremor or swelling.,GYN: See HPI.,Integumentary: Patient performs self-breast examinations and denies any breast masses or nipple discharge. No recent skin or hair changes.,Neuropsychiatric: Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS: Height 64.5 inches. Weight: 162 pounds. Blood pressure 104/72. Pulse: 72. Respirations: 16. LMP: 08/21/04. Age: 19.,HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation.,Neck: Full range of motion. No lymphadenopathy or thyromegaly.,Chest: Clear to auscultation and percussion.,Heart: Normal sinus rhythm, no murmur.,Integumentary: Breasts are without masses, tenderness, nipple retraction or discharge. Reviewed self-breast examination. No axillary nodes are palpable.,Abdomen: Soft. Liver, spleen, and kidneys are not palpable. No masses felt, nontender. Femoral pulses strong and equal.,Back: No CVA or spinal tenderness. No deformity noted.,Pelvic: BUS negative. Vaginal mucosa pink, scanty discharge. Cervix without lesion. Pap was taken. Uterus normal size. Adnexa: No masses. She does have some pain on palpation of the uterus.,Rectal: Good sphincter tone. No masses. Stool is guaiac negative.,Extremities: No edema. Pulses strong and equal. Reflexes are intact.,Rectal: No mass.,ASSESSMENT:, Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:, We will evaluate with a CBC, urinalysis and culture, and TSH. The patient has what she describes as migraine headaches of a new onset. Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram. We will evaluate with a CT scan of the brain with and without contrast. We will try Anaprox DS one every 12 hours for the headache. At this point, she could also use that for menstrual cramping. Prescription written for 20 tablets. If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow. The lab x-ray and urinalysis results will be reported to her as soon as they are available." }

[ { "label": " Obstetrics / Gynecology", "score": 1 } ]

{ "text_length": 4668 }

{ "text": "CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly \"normal.\",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 1985 }

{ "text": "EXAM:,1. Diagnostic cerebral angiogram.,2. Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:, Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm. He was referred for a routine postop check angiogram. He is doing fine clinically. All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner. Patient was placed under general anesthesia for entire duration of the procedure. Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush. A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush. The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections. The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1. After that the diagnostic catheter was taken up into the distal internal carotid artery. SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire. The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1. 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery. Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1. The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis. Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1. LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS: The left internal carotid artery is of normal caliber. In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1. There is poor filling of the A2 through left internal carotid artery injection. There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally. Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2. RIGHT INTERNAL CAROTID ARTERY INJECTION: The right internal carotid artery is of normal caliber. There is opacification of the right ophthalmic and the posterior communicating artery. The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery. Right MCA along with the distal branches are filling normally. Capillary filling and venous drainage are normal.,3. POST-PAPAVERINE INJECTION: The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery. Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1. Well clipped left ICA bifurcation aneurysm.,2. Moderately severe spasm of the internal carotid artery and left A1. 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels." }

[ { "label": " Neurology", "score": 1 } ]

{ "text_length": 3797 }

{ "text": "The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. The abdomen demonstrated some inflammation around the gallbladder. A 10-mm midepigastric trocar was inserted. A. 2 mm and 5 mm trocars were inserted. The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction. The cystic artery was identified and double Hemoclips applied. The gallbladder was taken down from the liver bed using Endoshears and electrocautery. Hemostasis was obtained. The gallbladder was removed from the midepigastric trocar site without difficulty. The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure well and was taken to the recovery room in stable condition." }

[ { "label": " Gastroenterology", "score": 1 } ]

{ "text_length": 1235 }

{ "text": "CHIEF COMPLAINT:,1. Chronic lymphocytic leukemia (CLL).,2. Autoimmune hemolytic anemia.,3. Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:, Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES: ,Vicodin.,REVIEW OF SYSTEMS: ,The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:" }

[ { "label": " SOAP / Chart / Progress Notes", "score": 1 } ]

{ "text_length": 1169 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder. She has noticed increasing abdominal girth as well as increasing edema in her legs. She has been on Norvasc and lisinopril for years for hypertension. She has occasional sweats with no significant change in her bowel status. She takes her thyroid hormone apart from her Synthroid. She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec. Her amlodipine and lisinopril are on hold.,ALLERGIES:, Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:, As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds. Denies chest pain or palpitations. She has some loosening stools, but denies abdominal pain. Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL: She is an obese female.,VITAL SIGNS: Blood pressure 140/70 and heart rate 84. She is afebrile.,HEENT: She has no periorbital edema. Extraocular movements were intact. There was moist oral mucosa.,NECK: Supple. Her thyroid gland is atrophic and nontender.,CHEST: Good air entry.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Benign.,EXTREMITIES: Showed 1+ edema.,NEUROLOGIC: She was awake and alert.,LABORATORY DATA:, TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:, This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago. She is clinically and biochemically euthyroid. Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine. I will continue on 300 mcg daily of Synthroid. If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid." }

[ { "label": " Endocrinology", "score": 1 } ]

{ "text_length": 2664 }

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

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 3973 }

{ "text": "ADMITTING DIAGNOSES:, Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4. During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS: ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed. A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty. Plan was to remove the stent. At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement. He has had no recent cold or flu. He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies. Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:, A 14-organ system review of systems is negative except for the history of present illness. He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:, Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL: The patient is an active little boy.,HEENT: The head and neck exam was grossly normal. He had no oral, ocular, or nasal discharge.,LUNGS: Exam was normal without wheezing.,HEART: Without murmur or gallops.,ABDOMEN: Soft, without mass or tenderness with a well-healed flank incision.,GU: Uncircumcised male with bilaterally descended testes.,EXTREMITIES: He has full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,BACK: He has normal back. Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy. He was made NPO. He had a fever at first time with elevated creatinine. He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure. Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty. He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy. The patient had draining nephrostomy tube without difficulty.," }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 3456 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X." }

[ { "label": " SOAP / Chart / Progress Notes", "score": 1 } ]

{ "text_length": 2575 }

{ "text": "PAST MEDICAL HISTORY: Include:,1. Type II diabetes mellitus.,2. Hypertension.,3. Hyperlipidemia.,4. Gastroesophageal reflux disease.,5. Renal insufficiency.,6. Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7. Enterocutaneous fistula.,8. Respiratory failure.,9. History of atrial fibrillation.,10. Obstructive sleep apnea.,11. History of uterine cancer, status post total hysterectomy.,12. History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY: The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY: Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS: Currently include,,1. Albuterol inhaler q.4 h.,2. Paradox swish and spit mouthwash twice a day.,3. Digoxin 0.125 mg daily.,4. Theophylline 50 mg q.6 h.,5. Prozac 20 mg daily.,6. Lasix 40 mg daily.,7. Humulin regular high dose sliding scale insulin subcu. q.6 h.,8. Atrovent q.4 h.,9. Lantus 12 units subcu. q.12 h.,10. Lisinopril 10 mg daily.,11. Magnesium oxide 400 mg three times a day.,12. Metoprolol 25 mg twice daily.,13. Nitroglycerin topical q.6 h.,14. Zegerid 40 mg daily.,15. Simvastatin 10 mg daily.,ALLERGIES: Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS: The patient currently denies any pain, denies any headache or blurred vision. Denies chest pain or shortness of breath. She denies any nausea or vomiting. Otherwise, systems are negative.,PHYSICAL EXAM:,General: The patient is awake, alert, and oriented. She is in no apparent respiratory distress.,Vital Signs: Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24. The patient has a tracheostomy in place. She will also have an esophageal gastric tube in place.,Cardiac: Regular rate and rhythm without audible murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases. No adventitious sounds are noted.,Abdomen: Obese. There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery. The area is covered with bandage with serosanguineous fluid. Abdomen is nontender to palpation. Bowel sounds are heard in all 4 quadrants.,Extremities: Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA: Pending. Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT: This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN: For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours. The patient had been previously controlled on this. We will continue to check her sugars every 6 hours and adjust insulin as necessary." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 2932 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:, Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:, Excision of right breast mass.,PROCEDURE:, With the patient in the supine position, the right breast was prepped and draped in a sterile fashion. A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast. Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue. Hemostasis was obtained using electrocautery. Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign. The breast tissues were approximated using 4-0 Vicryl. The skin was closed using 5-0 Vicryl running subcuticular stitches. A sterile bandage was applied. The patient tolerated the procedure well.," }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 930 }

{ "text": "EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no significant surrounding soft tissue swelling.,IMPRESSION: ,Negative right ankle." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 398 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 409 }

{ "text": "HISTORY:, Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:, FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacity was 71%. Expiratory residual volume was 61%. The TGV was 94%. Residual volume was 113% of its predicted. Total lung capacity was 83%. Diffusion capacity was diminished.,IMPRESSION:,1. Moderate restrictive lung disease.,2. Some reversible small airway obstruction with improvement with bronchodilator.,3. Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4. Flow volume loop was consistent with the above and no upper airway obstruction.," }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 814 }

{ "text": "CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 3132 }

{ "text": "ALLOWED CONDITIONS:, Sprain of left knee and leg.,CONTESTED CONDITION:, Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:, YYYY,REQUESTING PARTY:, XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the left leg. The injured worker does state that he was working as a processor for the ABCD Company on July 18, 2007, when he injured his left knee. He does state he was working in a catwalk when he stepped up. He noticed his sight glass was not open on the tank. He then stepped straight down and his knee went sideways. His knee popped and he sat down secondary to discomfort. At that time he could not do any type of activity secondary to the pain. The nurse called the ambulance subsequent to this injury and he was taken to Bethesda North. X-rays were obtained which demonstrated no evidence of fracture. Thereafter, he was referred to X who he saw on July 19, 2007. It was felt that a MRI scan about the knee needed to be obtained and it was obtained on July 24. It was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear. On his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.,On September 7, 2007, he underwent surgical intervention at ABC for the anterior cruciate reconstruction as well as the partial medial meniscectomy.,At the present time, he is progressing along with physical therapy. He is utilizing one crutch.,He does admit to significant bruising and swelling about the left lower extremity. If he does indeed move too fast, the discomfort is increased. His pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.,He has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.,He underwent arthroscopic surgery as related to the right knee at that time and really did quite well.,His next appointment with Dr. X is on October 4, 2007.,The injured worker denies any previous history of similar problems as related to the left knee.,MEDICATIONS: , Glucophage, Lipitor, Actos, Benicar, glimepiride, and Januvia.,SURGICAL HISTORY:, Arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.,SOCIAL HISTORY:, The patient denies alcohol consumption. He does smoke approximately one and a half packs of cigarettes per day. His education is that of 12th grade.,PHYSICAL EXAMINATION: , This is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds. He does not appear to be in distress at this time. Examination is limited to the left knee. One could appreciate a healed scar as related to the inferior pole inferior to the patella. There are healed arthroscopic scars as well. The range of motion of left knee reveals 50 to 70 degrees of flexion. There is evidence of medial and lateral joint line discomfort. Anterior Lachman's test was negative. No evidence of atrophy is noted. There is weakness with aggressive function about the quadriceps and hamstring musculature.,The patient is ambulating with one crutch at this time.,There is mild degree of swelling as related to the left knee. Deep tendon reflexes are +2/+2 bilaterally symmetrical. Sensory examination was normal as related to the foot, but abnormal as related to the left knee.,I did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.,MEDICAL RECORDS REVIEW:,1. July 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion. It should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort. There was specific mention of intraarticular effusion.,2. On July 27, 2007, MRI scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal ACL. Findings suggestive of a chronic injury. Grade I sprain of the MCL was noted. Contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted. There was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus. Chondromalacia of the lateral femoral condyle and patella was noted. It should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the July 18, 2007, injury.,3. July 18, 2007, first report of injury, occupational disease, and/or death.,4. Evaluations of ABCD Hospital. It should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.,5. July 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis. There is evidence there maybe a small suprapatellar joint effusion.,6. Notes from the office of Dr. X. It should be noted on physical examination his range of motion is 8 to 20 degrees.,7. Physical therapy prescription for __________ Orthopedics and Sports Medicine Corporation.,8. August 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.,9. Physician narrative of August 24, 2007. It is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes. His BMI was 42. This was felt __________ pre-injury MRI scan.,Following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions. Please express your opinion based upon a reasonable degree of medical probability.,QUESTION: ,Mr. XXXXXX has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee ACL tear.,Based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.,ANSWER: ,The MRI sustains and verifies that these conditions do indeed exist subsequent to the injury of July 18, 2007.,QUESTION: ,If you find any of these conditions exist, are they a direct and proximate result of the July 18, 2007, injury.,ANSWER: ,There is mention of degeneration as related to the knee prior to this episode. This is not surprising considering the individual's weight. There is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time. There has been an aggravation of this condition. Without having a MRI to review prior to this injury, I believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology. Thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the July 18, 2007, injury.,QUESTION: " }

[ { "label": " IME-QME-Work Comp etc.", "score": 1 } ]

{ "text_length": 7147 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED: ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy. He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules. He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months. Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder. Scarring was noted along the base of the bladder from the patient's previous cysto TURBT. Ureteral orifice on the right side was not able to be identified. The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room. He was placed on the operating table. General anesthesia was administered after which the patient was placed in the dorsal lithotomy position. The genitalia and lower abdomen were prepared with Betadine and draped subsequently. The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above. Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area. Each of these biopsy sites were fulgurated with Bugbee electrodes. Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear. The patient's bladder was then emptied. Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area. There were no apparent complications, and the patient appeared to tolerate the procedure well. Estimated blood loss was less than 15 mL." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 2235 }

{ "text": "PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:, Prozac 20 mg q.d. She desires to be on the NuvaRing.,ALLERGIES:, Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:, VITALS: Stable. Weight: 114 lb. Height: 5 feet 2 inches. GENERAL: Well-developed, well-nourished female in no apparent distress. HEENT: Within normal limits. NECK: Supple without thyromegaly. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft and nontender. There is no rebound or guarding. No palpable masses and no peritoneal signs. EXTREMITIES: Within normal limits. SKIN: Warm and dry. GU: External genitalia is without lesion. Vaginal is clean without discharge. Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal. BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness. She had no tenderness in her adnexa. There are no palpable masses.,A:, Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease. GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg. Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A. A LEEP is a reasonable approach even in this 16-year-old.,P:, We will schedule LEEP in the near future. Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions. Now, we have her given her first shot." }

[ { "label": " Obstetrics / Gynecology", "score": 1 } ]

{ "text_length": 1750 }

{ "text": "CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:, This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS.,Overall, he is doing well. Since I last saw him, he tells me that he has had onset of atrial fibrillation. He has now started going to the gym two times per week, and has lost over 10 pounds. He has a good energy level and his ECOG performance status is 0. He denies any fever, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax 0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES: ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. He is status post left inguinal hernia repair.,2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:" }

[ { "label": " Hematology - Oncology", "score": 1 } ]

{ "text_length": 1601 }

{ "text": "RIGHT:,1. Mild heterogeneous plaque seen in common carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5. Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1. Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3. Peak systolic velocity is normal in common carotid artery and in the bulb.,4. Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:, Antegrade flow seen bilaterally." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 896 }

{ "text": "PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:, Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:, C5-C6 and C6-C7 anterior cervical discectomy (two levels) 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.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy. After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees. A shoulder roll was placed and the head supported on a donut support. The cervical region was prepped and draped in the standard fashion. A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy. Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint. On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. This was done under the microscope. A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level. This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. With this done, the wound was irrigated. Hemostasis was ensured with bipolar coagulation. Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites. Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed. A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7. The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7. With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient remained hemodynamically stable throughout the procedure. Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure. The patient remained stable throughout the procedure." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 5840 }

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

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 5015 }

{ "text": "PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and this is persistent. Therefore, he came in for cardioversion today. He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices. After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s. He tolerated it well. He will be observed for couple hours and discharged home later today. He will continue on his current medications. He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 1080 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Acute appendicitis.,2. 29-week pregnancy.,POSTOPERATIVE DIAGNOSES,1. Acute appendicitis.,2. 29-week pregnancy.,OPERATION: , Appendectomy.,DESCRIPTION OF THE PROCEDURE: ,After obtaining the informed consent including all risks and benefits of the procedure, the patient was urgently taken to the operating room where a spinal anesthetic was given and the patient's abdomen was prepped and draped in a usual fashion. Preoperative antibiotics were given. A time-out process was followed. Local anesthetics were infiltrated in the area of the proposed incision. A modified McBurney incision was performed. A very abnormal appendix was immediately found. There was a milky fluid around the area and this was cultured both for aerobic and anaerobic cultures. The distal end of the appendix had transformed itself into an abscess. The proximal portion was normal. The appendix was very friable and a no-touch technique was used. It was carefully dissected off the cecum, and then it was ligated and excised after the mesoappendix had been taken care of. Then the stump was buried with a pursestring of 2-0 Vicryl. The operative area was abundantly irrigated with warm saline and then closed in layers. The layer was further irrigated. A subcuticular suture of Monocryl was performed in the skin followed by the application of Dermabond.,Further local anesthetic was infiltrated at the end of the procedure in the operative area and the patient tolerated the procedure well, and with an estimated blood loss that was not consequential, was transferred from recovery to ICU in a satisfactory condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 1638 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago. Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions. She had requested a procedure to bring about further facial asymmetry. She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate. She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left. Preoperative workup including CT scan failed to show any skeletal trauma. The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:, The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake. General endotracheal anesthesia was induced with a #6 endotracheal tube. All appropriate measures were taken to preserve the vocal cords in a professional singer. Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia. The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine. Adequate time for vasoconstriction and anesthesia was allowed to be obtained. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture was placed in the right lower lid. For traction, it was brought anteriorly. The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe. A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone. The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present. The inferior oblique muscle was identified, preserved, and protected throughout the procedure. The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut. Contralateral side was treated in similar fashion with like results and throughout the procedure. Lacri-Lube was in the eyes in order to maintain hydration. Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds. Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia. A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane. Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle. The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle. It was bipolar electrocauteried and the tunnel was further dissected free and opened. The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection. The guard was removed and the suspension spikes were engaged into the soft tissues. The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally. The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture. Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained. The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples. The sterile dressing was applied. The patient was awakened in the operating room and taken to the recovery room in good condition." }

[ { "label": " Cosmetic / Plastic Surgery", "score": 1 } ]

{ "text_length": 5154 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1. Open reduction and internal screw fixation right fifth metatarsal.,2. Application of short leg splint.,ANESTHESIA:, TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal. The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot. She continued to walk on the foot and found nothing was wrong despite the pain. She was recently seen by Dr. X and was referred to Dr. Y for surgery. The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y. The consent is available on the chart for review. The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL: ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and a sterile stocking was reflected. Attention was directed to the right fifth metatarsal base. The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal. An avulsion fracture of the right fifth metatarsal base was visualized. The fracture was linear in nature from distal lateral to proximal medial. There appeared to be a pseudoarthrosis on the lateral view. A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve. A linear incision was created with a #10 blade. A #15 blade was used to deepen the incision through the subcutaneous tissue. All small veins traversing the subcutaneous tissue were ligated with electrocautery. Next, using combination of sharp and blunt dissection, the deep fascia was reached. Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade. Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone. The fracture site was not clearly visualized due to bony callus. A #25 gauge needle was introduced into the fracture site under fluoroscopy. The fracture site was easily found. An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone. Next, a small ball burr was used to resect the remaining hypertrophic bone. Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone. Next, a bone clamp was applied and the fracture was reduced. Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally. A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly. All this was done under fluoroscopy. Next, the wound was flushed with copious amounts of sterile saline. The fracture site was found to have rigid compression. The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed. Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion. A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique. Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique. A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance. A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot. Next, copious amounts of Webril were applied to pad all bony prominences. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. Next, 4-inch, pre-moulded, well-padded posterior splint was applied. The capillary refill time of the digits was less than three seconds. The patient tolerated the above anesthesia and procedure without complications. After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone. She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches. She will rest, ice, and elevate her right leg. She is to follow up in the clinic on 08/26/03 at 10:30 a.m.. She was given emergency contact numbers and will call or return if problems arise earlier." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 5754 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose. The patient was on vancomycin for the last 5 days.,BRIEF HISTORY: ,The patient is a 53-year-old female who presented with Enterococcus urosepsis. CT scan showed a lower pole stone with a stent in place. The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology. The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. There was some pus that came out. The patient was cultured; actually it was negative at that time. The patient subsequently was found to have lower extremity DVT and then was started on Coumadin. The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE. The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact. The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers. The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated. Due to drug interaction, the patient was admitted for IV antibiotic treatment. The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. Since the stone is not obstructing, there is no reason to replace the stent at this time. We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient. Risks, benefits, and options were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. The patient understood all the risks and benefits of removing the stent and wanted to proceed. The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was given some IV pain meds. The patient had received vancomycin and Levaquin preop. Cystoscopy was performed using graspers. The stent was removed without difficulty. Plan was for repeat cultures and continuation of the IV antibiotics." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 3013 }

{ "text": "SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 1839 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2. Recurrent dysplasia.,3. Unable to follow in office.,4. Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III postconization.,2. Poor margins.,3. Recurrent dysplasia.,4. Uterine procidentia grade II-III.,5. Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1. Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2. Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS: ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS: ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS: ,On bimanual examination, the uterus was found to be small. There were no adnexal masses appreciated. Intraabdominal findings revealed a small uterus approximately 2 cm in size. The ovaries were atrophic consistent with menopause. The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control. She was then placed in the dorsal lithotomy position and administered general anesthesia. She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder. At this point, the patient was evaluated for a possible vaginal hysterectomy. She was nulliparous and the pelvis was narrow. After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy. After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis. The second scalpel was used to dissect out to the underlying layer of fascia. The fascia was incised in the midline and extended laterally using the Mayo scissors. The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors. In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors. The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum. The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder. At this point, the above findings were noted and the GYN Balfour retractor was placed. Moist laparotomy sponges were used to pack the bowel out of the operative field. The bladder blade and the extension for the retractor were then placed. An Allis was used on the uterus for retraction. The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated. The anterior portion of the broad ligament was dissected along vesicouterine resection. The bladder was then dissected off the anterior cervix and vagina without difficulty. The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture. The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl. Good hemostasis was assured. The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl. Good hemostasis was obtained. Two hemostats were then placed just under the cervix meeting in the midline. The uterus and cervix were then _______ off using a scalpel. This was handed and sent to Pathology for evaluation. Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament. A baseball stitch was then used to close the cuff to the midline. The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments. The baseball stitch was used to close the cuff to the midline. The hemostats were removed and the cuff was closed and good hemostasis was noted. The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff. The pelvis was then copiously irrigated with warm normal saline. Good support and hemostasis was noted. The bowel packing was then removed and the GYN Balfour retractor was moved. The peritoneum was then repaired with #0 Vicryl in a running fashion. The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion. The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this. The patient was then brought out of general anesthesia and extubated. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She will follow up postoperatively as an inpatient." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 5362 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Vault prolapse.,2. Enterocele.,PREOPERATIVE DIAGNOSES:,1. Vault prolapse.,2. Enterocele.,OPERATIONS:,1. Abdominosacrocolpopexy.,2. Enterocele repair.,3. Cystoscopy.,4. Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:, The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse. The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse. Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars. Risk of open surgery was little bit higher for the patient. After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed. The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure. The patient was told to perform no heavy lifting for 3 months, etc. The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A Pfannenstiel low abdominal incision was done at the old incision site. The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle. The muscle was split in the middle and peritoneum was entered using sharp mets. There was no injury to the bowel upon entry. There were significant adhesions which were unleashed. All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized. There was minimal space, everything was packed, Bookwalter placed then over the sacral bone. The middle of the sacral bone was identified. The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened. The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3. A 1 cm x 5 cm mesh was cut out. This was a Prolene soft mesh which was tied at the sacral ligament. The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3. The mesh was attached. The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty. The ureter was not involved at all in this process. The peritoneum was closed over the mesh. Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel. Prior to closure antibiotic irrigation was done using Ancef solution. The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution. All the solution was removed. Good hemostasis was obtained. All the packing was removed. Count was correct. Rectus abdominus muscle was brought together using 4-0 Vicryl. The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle. Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion. Cystoscopy was done at the end of the procedure. Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure. Cystoscopy was done and indigo carmine has been given. There was good efflux of indigo carmine in both of the ureteral opening. There was no injury to the rectum or the bladder. The bladder appeared completely normal. The rectal exam was done at the end of the procedure after the cystoscopy. After the cysto was done, the scope was withdrawn, Foley was placed back. The patient was brought to recovery in the stable condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 4162 }

{ "text": "ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm.,7. Alcohol abuse, not otherwise specified.,8. Aftercare healing traumatic lower leg fracture.,9. Open wound of the scalp.,10. Cervical disk displacement with myelopathy.,11. Episodic mood disorder.,12. Anxiety disorder.,13. Nervousness.,14. Psychosis.,15. Generalized pain.,16. Insomnia.,17. Pain in joint pelvic region/thigh.,18. Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:, None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE: ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1. Calcium with vitamin D 1 tablet twice a day.,2. Ferrous sulfate 325 mg t.i.d.,3. Multivitamin 1 daily.,4. He was on nicotine patch 21 mg per 24 hour.,5. He was on Seroquel 25 mg at bedtime.,6. He was on Xenaderm for his sacral pressure ulcer.,7. He was on Vicodin p.r.n. for pain.,8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge." }

[ { "label": " Discharge Summary", "score": 1 } ]

{ "text_length": 3880 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Ectopic pregnancy.,3. Hemoperitoneum.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Right salpingectomy.,4. Lysis of adhesions.,5. Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:, Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile. No adnexal masses, however, were appreciated on the bimanual exam. Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. There were also adhesions to the left fallopian tube and the right fallopian tube. There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. There was some questionable gestational tissue ________ on the left sacrospinous ligament. There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:, After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. A weighted speculum was then placed in the vagina. The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. Next, attention was then turned to the abdomen. The surgeons all are removed the dirty gloves in the previous portion of the case. Next, a 2 cm incision was made immediately inferior to umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision. Next, a syringe was used to inject normal saline into the Veress needle. The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting. The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting. The abdomen was insufflated to an adequate distension. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted. Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. A Veress needle and a step sheath were inserted through this incision. Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization. Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen. Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port. Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. This was then sent to the pathology. Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. The abdomen was further irrigated. The liver was examined and appeared to be within normal limits. At this point, the two size #5 ports and a size #12 port were removed under direct visualization. The camera was then removed. The CO2 gas was disconnected and the abdomen was desufflated. The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion. They were then steri-stripped and bandaged appropriately. At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She was discharged home with a postoperative hemoglobin of 8.9. She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain. She will follow up within a week in the OB resident clinic." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 5910 }

{ "text": "CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: ,Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.,Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1. Negative for pulmonary arterial embolism.,2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3. Cardiomegaly with mitral valvular calcifications.,4. Postsurgical changes of a left upper lobectomy.,5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 1473 }

{ "text": "1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2. The left atrium appears mildly dilated.,3. The right atrium and right ventricle appear normal.,4. The aortic root appears normal.,5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.,8. The pulmonary valve appears normal with trace pulmonary insufficiency.,9. There is no pericardial effusion or intracardiac mass seen.,10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.," }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 1618 }

{ "text": "DISCHARGE DIAGNOSES:,1. End-stage renal disease, on hemodialysis.,2. History of T9 vertebral fracture.,3. Diskitis.,4. Thrombocytopenia.,5. Congestive heart failure with ejection fraction of approximately 30%.,6. Diabetes, type 2.,7. Protein malnourishment.,8. History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008. The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization. He also needed to continue with dialysis and he needed to improve his rehabilitation. The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles. He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management. The patient had remained afebrile. He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise. On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid. He denied any complaints of pain. He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day. The patient has increased his appetite some and has been eating some. His vital signs remain stable. His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3. PPD was negative. An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it. He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him. He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.," }

[ { "label": " Nephrology", "score": 1 } ]

{ "text_length": 2162 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is 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 although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist." }

[ { "label": " General Medicine", "score": 1 } ]

{ "text_length": 7481 }

{ "text": "SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A 360-degree limbal conjunctival peritomy was created with Westcott scissors. Curved tenotomy scissors were used to enter each of the intermuscular quadrants. The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture. The 3 other rectus muscles were isolated in a similar fashion. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma." }

[ { "label": " Ophthalmology", "score": 1 } ]

{ "text_length": 731 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose. The patient was on vancomycin for the last 5 days.,BRIEF HISTORY: ,The patient is a 53-year-old female who presented with Enterococcus urosepsis. CT scan showed a lower pole stone with a stent in place. The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology. The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. There was some pus that came out. The patient was cultured; actually it was negative at that time. The patient subsequently was found to have lower extremity DVT and then was started on Coumadin. The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE. The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact. The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers. The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated. Due to drug interaction, the patient was admitted for IV antibiotic treatment. The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. Since the stone is not obstructing, there is no reason to replace the stent at this time. We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient. Risks, benefits, and options were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. The patient understood all the risks and benefits of removing the stent and wanted to proceed. The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was given some IV pain meds. The patient had received vancomycin and Levaquin preop. Cystoscopy was performed using graspers. The stent was removed without difficulty. Plan was for repeat cultures and continuation of the IV antibiotics." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 3013 }

{ "text": "FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament." }

[ { "label": " Orthopedic", "score": 1 } ]

{ "text_length": 2014 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE: ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure. A speculum was placed into the vagina. A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix. The uterus was sounded to 10.5 cm. A #10 RUMI cannula was utilized and attached for uterine manipulation. The single-tooth tenaculum and speculum were removed from the vagina. At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity. Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide. After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity. Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted. At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine. A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation. Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular. The fallopian tubes have been previously interrupted surgically. The ovaries appeared normal bilaterally. The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions. The ureters were noted to be deep in the pelvis. At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty. The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. A similar procedure was carried out on the left with the left uterine cornu identified. The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected. The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection. At this time, attention was made to the vaginal hysterectomy. The laparoscope was removed and attention was made to the vaginal hysterectomy. The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum. A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio. A circumferential incision was then made at the cervicovaginal portio. The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty. The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures. The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture. The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally. The uterus was then removed and passed off the operative field. Laparotomy pack was placed into the pelvis. The pedicles were evaluated. There was no bleeding noted; therefore, the laparotomy pack was removed. The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures. The vaginal cuff was then closed in a running fashion with #0 Vicryl suture. Hemostasis was noted throughout. At this time, the laparoscope was reinserted into the abdomen. The abdomen was reinsufflated. Evaluation revealed no further bleeding. Irrigation with sterile water was performed and again no bleeding was noted. The suprapubic trocar sheath was then removed under laparoscopic visualization. The laparoscope was removed. The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed. The skin incisions were closed with #4-0 Vicryl in subcuticular fashion. Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition. Estimated blood loss was approximately 100 mL. There were no complications. The instrument, sponge, and needle counts were correct." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 5153 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He was seen a few weeks ago for routine followup, and he was noted for microhematuria. Due to his history of kidney stone, renal ultrasound as well as IVP was done. He presents today for followup. He denies any dysuria, gross hematuria or flank pain issues. Last stone episode was over a year ago. No history of smoking. Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis. IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis. The calcification previously noted on the ureter appears to be outside the course of the ureter. Otherwise unremarkable. This is discussed.,IMPRESSION: ,1. A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. The patient is asymptomatic. We have discussed surgical intervention versus observation. He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2. Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future. Urine sent for culture and sensitivity.,PLAN: , As above. The patient will follow up for cystoscopy, urine sent for cytology, continue hydration. Call if any concern. The patient is seen and evaluated by myself." }

[ { "label": " Urology", "score": 1 } ]

{ "text_length": 1629 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2. Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure. The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region. This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease. The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion. The area was dressed with antibiotic ointment and then a Peri-Pad. The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes. Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex. Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized. Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple. At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple. When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft. At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola. At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic. The areolar skin graft was pie crusted. Then, at this point, the area of areola was dressed with silicone gel sheeting. A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position. Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made. The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out. When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision. Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola. The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 3744 }

{ "text": "PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back." }

[ { "label": " Neurosurgery", "score": 1 } ]

{ "text_length": 4364 }

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

[ { "label": " SOAP / Chart / Progress Notes", "score": 1 } ]

{ "text_length": 2276 }

{ "text": "FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d." }

[ { "label": " Discharge Summary", "score": 1 } ]

{ "text_length": 2550 }

{ "text": "CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired." }

[ { "label": " Neurology", "score": 1 } ]

{ "text_length": 3510 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed. She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement. I met with the patient's mom. With the help of a Spanish interpreter, I explained the technique for Broviac placement. We discussed the surgical risks and alternatives, most of which have been exhausted. All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION: ,The patient came to the operating room and had an uneventful induction of general anesthesia. We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter. Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath. There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. Heparinized saline solution was used to flush the line. A sterile occlusive dressing was applied, and the line was prepared for immediate use. The patient was transported to the recovery room in good condition. There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure." }

[ { "label": " Pediatrics - Neonatal", "score": 1 } ]

{ "text_length": 2826 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76" }

[ { "label": " Ophthalmology", "score": 1 } ]

{ "text_length": 3550 }

{ "text": "ADMISSION DIAGNOSES:,1. Menorrhagia.,2. Uterus enlargement.,3. Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period. She also had symptoms of back pain, dysmenorrhea, and dysuria. The symptoms had been worsening over time. The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:, The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE: ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy. The procedure preceded as planned without complication. Uterus was sent for pathologic analysis. The patient was monitored in the hospital, 2 days postoperatively. She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION: ,The patient was discharged to home in stable condition. She was instructed to follow up in the office postoperatively." }

[ { "label": " Discharge Summary", "score": 1 } ]

{ "text_length": 1389 }

{ "text": "CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:, Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle.,REVIEW OF SYSTEMS:, He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising.,MEDICATIONS:, No daily medications.,ALLERGIES:, Cefzil.,IMMUNIZATIONS:, His immunizations are up to date.,PHYSICAL EXAMINATION:,General: He is alert and in no distress, afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Tanner III.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. No rashes.,Hearing: Grossly normal.,ASSESSMENT:, Well child.,PLAN:, Anticipatory guidance for age. He is to return to the office in one year." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 2222 }

{ "text": "DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 3866 }

{ "text": "OPERATION,1. Insertion of a left subclavian Tesio hemodialysis catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition." }

[ { "label": " Cardiovascular / Pulmonary", "score": 1 } ]

{ "text_length": 1625 }

{ "text": "PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:, Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery. The patient was brought to the GI lab. There, she was placed in partial left lateral decubitus position. She was given IV sedation by Anesthesia. Her abdomen was prepped with alcohol and then Betadine. Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum. No lesions were noted in the duodenum. There appeared to be a few polyps in the antral area, two in the antrum. Actually, one appeared to be almost covering the pylorus. The scope was withdrawn back into the antrum. On retroflexion, we could see a large hiatal hernia. No other lesions were noted. Biopsy was taken of one of the polyps. The scope was left in position. Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area. A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth. Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall. It was held in position with a dressing and a stent. A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature. The patient tolerated the procedure well. She was returned to the floor in stable condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 1850 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2. Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe. The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area. The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position. After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc. Following this, the patient was draped and prepped in a normal sterile orthopedic manner. An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot. The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table. The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined. The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit. Then using a fresh #15 blade, skin incision was made. Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue. Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion. The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety. The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within. The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum. Remaining tissues were inspected and appeared healthy. The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth. Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx. The capsule was also reflected to expose the prominent lateral osseous portion of this joint. Using a sagittal saw and #139 blade, the lateral osseous prominence was resected. This was removed in entirety. Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition. Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin. Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin. Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion. The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot. The patient was then escorted from the operative table into the Postanesthesia Care Unit. The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact. In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation. The patient was also given instructions as to signs of infection and to monitor her operative site. The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 4917 }

{ "text": "CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with \"bone cancer.\" AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992." }

[ { "label": " Neurology", "score": 1 } ]

{ "text_length": 1998 }

{ "text": "EXAM: , Five views of the right knee.,HISTORY: , Pain. The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:, Five views of the right knee were evaluated. There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations. There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia. There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1. No evidence of any displaced fractures, dislocations, or subluxations.,2. Growth arrest lines seen in the distal femur and proximal tibia.,3. Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta." }

[ { "label": " Radiology", "score": 1 } ]

{ "text_length": 855 }

{ "text": "EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 3795 }

{ "text": "CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110. HR 85. RR 16. Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done." }

[ { "label": " Neurology", "score": 1 } ]

{ "text_length": 2999 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:, In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 1860 }

{ "text": "REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However, she was complaining of chest pain. She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough. When she did cough, it was nonproductive. While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently, an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease.,2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease.,3. Renal cell carcinoma - She is status post nephrectomy.,4. Hypertension.,5. Anxiety disorder.,6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7. Ongoing tobacco use.,PAST SURGICAL HISTORY,1. Recent and multiple thoracentesis as described above.,2. Bilateral mastectomies.,3. Multiple abdominal surgeries.,4. Cholecystectomy.,5. Remote right ankle fracture.,ALLERGIES:, No known drug allergies.,MEDICATIONS: , At home,,1. Atenolol 50 mg daily,2. Ativan p.r.n.,3. Clonidine 0.1 mg nightly.,4. Compazine p.r.n.,5. Dilaudid p.r.n.,6. Gabapentin 300 mg p.o. t.i.d.,7. K-Dur 20 mEq p.o. daily.,8. Lasix unknown dose daily.,9. Norvasc 5 mg daily.,10. Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:, Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL: She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount. HEENT: She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears. CHEST: Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis. CVS: She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations. GI: No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools. GU: No dysuria, burning with urination, kidney stones, and difficulty voiding. MUSCULOSKELETAL: No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness. NEUROLOGIC: She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS: Her T-max is 99.3. Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL: Somewhat fatigued appearing but in no acute distress.,HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema, exudate, or discharge.,NECK: Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules.,CHEST: Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS: Regular rate and rhythm. No murmurs, gallops or rubs. Normal S1 and S2. No S3 or S4.,ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 6280 }

{ "text": "REASON FOR CONSULTATION:, Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1. Graves disease.,2. Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3. Diverticulosis.,4. GERD.,5. High blood pressure.,6. Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT: ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today. Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking. On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No recent fever or general malaise.,ENT: Unremarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: No chest pain.,GASTROINTESTINAL: No nausea or vomiting.,GENITOURINARY: The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE: Negative for diabetes, but positive for Graves disease.,MEDICATIONS: ,The patient takes Synthroid and aspirin. Aspirin had been discontinued about 1 week ago. He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL: A 71-year-old gentleman, not in acute distress.,CHEST: Clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: There is no swelling.,NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal.,ASSESSMENT AND PLAN:,1. Perioperative hypertension. We will restart lisinopril at half the previous dose. He will be on 20 mg p.o. daily. If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily. The patient should see his primary physician, Dr. Y in 2 weeks' time. If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2. Prostatic hypertrophy, status post laser surgery. The patient tolerated the procedure well.,3. History of Graves disease.,4. History of atrial fibrillation. The patient is in normal sinus rhythm.,DISPOSITION: ,The patient is stable to be discharged to home. Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 2894 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1. Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2. Sharp excision of left distal foot plantar fascia.,ANESTHESIA:, None required.,INDICATIONS:, The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:, The procedure was performed in the patient's room. The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure." }

[ { "label": " Surgery", "score": 1 } ]

{ "text_length": 2036 }

{ "text": "DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required." }

[ { "label": " General Medicine", "score": 1 } ]

{ "text_length": 2252 }

{ "text": "EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1. Stable mammographic appearance from mm/dd/yy.,2. No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign" }

[ { "label": " Obstetrics / Gynecology", "score": 1 } ]

{ "text_length": 1157 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation." }

[ { "label": " Consult - History and Phy.", "score": 1 } ]

{ "text_length": 3765 }