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Argilla 192

{ "text": "PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:, Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom. The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem. The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, placed supine, put under general mask anesthesia. Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. There were some secretions but that looked okay. Got down at the level of the carina to see a foreign body flapping in the right main stem. I then used graspers to grasp to try to pull into the scope itself. I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper. It appeared to be consisting of some type of plastic piece that had broke off some different object. I took the scope and put it back down into the airway again. Again, there was secretion in the trachea that we suctioned out. We looked down into the right bronchus intermedius. There was no other pathology noted, just some irritation in the right main stem area. I looked down the left main stem as well and that looked okay as well. I then withdrew the scope. Trachea looked fine as well as the cords. I put the patient back on mask oxygen to wake the patient up. The patient tolerated the procedure well." }

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

{ "text_length": 1752 }

{ "text": "CHIEF COMPLAINT: , \"I want my colostomy reversed.\",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a \"bag.\" According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Question of hypertension.,3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4. Status post cholecystectomy.,7. Status post unknown foot surgery.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY: ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact.,NECK: Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR: Regular rate and rhythm.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN: ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.," }

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

{ "text_length": 4432 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:, Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , 15 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: , The patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified. Once he was anesthetized, a caudal block was placed. IV antibiotic was given. The dorsal hood was retracted and the patient was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed in the glans for traction. His urethra was calibrated, it was quite thin, to a 10-French with the straight sounds. We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors. Electrocautery was used for hemostasis. The ventral chordee tissue was removed. We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test, which showed that he had a persistent chordee. In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen. We then used a Heinecke-Mikulicz Nesbit tuck with 5-0 Prolene to straighten the penis. Artificial erection again performed showed the penis was straight. The knot was buried with figure-of-eight suture of 7-0 Vicryl in Buck fascia above it. We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade. We then elevated the glanular wings as well in the similar fashion. An 8-French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 Vicryl and then a running subcuticular closure of 7-0 Vicryl to close the defect. We then put the stay sutures in the inter-preputial skin with 7-0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors. We buttonholed the flap and then placed it through the penis as a sleeve. Interrupted sutures of 7-0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty. Once this was done, a two 5-0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis. Interrupted sutures of 7-0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 Vicryl used to reconstitute the glans. We then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures. We then closed the ventral defect. Once this was done, the stay suture in the glans was used to keep the Zaontz catheter to tack it into place. We then used Surgicel, Dermabond, and Telfa dressing with Mastisol and an eye tape to keep the dressing in place. IV Toradol was given at the end of the procedure. The patient was in stable condition upon transfer to the recovery room." }

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

{ "text_length": 3775 }

{ "text": "CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion. A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney. No calcifications are noted. The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended. The large and small bowels are normal in course and caliber. There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions." }

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

{ "text_length": 1151 }

{ "text": "PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis. Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction. There was no evidence of either inflammation or a fistulous opening. The scope was withdrawn. A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position). Some purulent material could be expressed through the opening. There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material. Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable. In addition, scars were noted in the perianal area. The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position. The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek. There were no other abnormalities noted. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal colonoscopy to the terminal ileum.,2. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1. Continue antibiotics.,2. Followup with Dr. X.,3. If drainage persists, consider surgical drainage." }

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

{ "text_length": 1914 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,POSTOPERATIVE DIAGNOSES:,1. Chronic eustachian tube dysfunction.,2. Retained right pressure equalization tube.,3. Retracted left tympanic membrane.,4. Dizziness.,PROCEDURE:,1. Removal of the old right pressure equalizing tube with placement of a tube. Tube used was Santa Barbara.,2. Myringotomy with placement of a left pressure equalizing tube. The tube used was Santa Barbara.,ANESTHESIA:, General.,INDICATION: , This is a 98-year-old female whom I have known for several years. She has a marginal hearing. With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly. So, we have kept sets of tubes in her ears at all times. The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed. There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia. Mask airway was used. IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant. In the same area, a small Santa Barbara tube was placed. This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated. Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis. Anterior, inferior incision was made. Tympanic membrane bounced back to neutral position. A Santa Barbara tube was cut to the 80% of the original length and placed in the hole. Ciprofloxacin drops were placed in the ear. Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:, None.,DISPOSITION:, To PACU in a stable condition." }

[ { "label": " ENT - Otolaryngology", "score": 1 } ]

{ "text_length": 2275 }

{ "text": "GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:, Clear to auscultation.,HEART:, Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.,ABDOMEN:, Soft with bowel sounds present. No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC: ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash." }

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

{ "text_length": 860 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:, Lumbar radiculopathy, 724.4.,PROCEDURE:, Lumbar epidural steroid injection.,ANESTHESIOLOGIST:, Monitored anesthesia care,INJECTATE USED:, 10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DETAILS OF THE PROCEDURE:, The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained. A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death. There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury. Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically. A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5. Needle tip position was confirmed in the anterior posterior fluoroscopic view. The epidural space was located with the loss of pulsation technique. Aspiration of the syringe was negative for blood or cerebrospinal fluid. One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:, Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient." }

[ { "label": " Pain Management", "score": 1 } ]

{ "text_length": 2251 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition." }

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

{ "text_length": 1742 }

{ "text": "PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma. ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST: Clear. There is no heart murmur.,ABDOMEN: Nontender.,PELVIC: There is a large mass in the vagina. ,HOSPITAL COURSE: , The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable., ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.,PATHOLOGY:, Mullerian adenosarcoma.,MEDICATIONS:, Percocet 5, #40, one q.3 h. p.r.n. pain." }

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

{ "text_length": 1086 }

{ "text": "VITRECTOMY 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 limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. Hemostasis was maintained with wet-field cautery. Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant. A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the preplaced sutures. An 8-0 nylon suture was then preplaced for a later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on. Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants." }

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

{ "text_length": 1258 }

{ "text": "DELIVERY NOTE:, The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting. She was Group B Streptococcus positive, however, was 5 cm dilated. The patient was started on Group B Streptococcus prophylaxis with ampicillin. She received a total of three doses throughout her labor. Her pregnancy was complicated by scanty prenatal care. She would frequently miss visits. At 37 weeks, she claims that she had a suspicious bump on her left labia. There was apparently no fluid or blistering of the lesion. Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2. I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery. The patient requested an epidural anesthetic, which she received with very good relief. She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions. She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum. The baby delivered in the occiput anterior position. The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated. The umbilical cord was doubly clamped and then cut. The baby's Apgars were 8 and 9. The placenta was delivered spontaneously intact. There was a three-vessel cord with normal insertion. The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol. The perineum was inspected and was found to be fully intact. Estimated blood loss was approximately 400 mL. The patient's blood type is A+. She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin." }

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

{ "text_length": 2370 }

{ "text": "REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:," }

[ { "label": " Pain Management", "score": 1 } ]

{ "text_length": 92 }

{ "text": "OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%. Small improvement is noted in the airflows after bronchodilator therapy. Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted. Single-breath diffusing capacity is slightly reduced.,IMPRESSION: , Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy." }

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

{ "text_length": 515 }

{ "text": "PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding. The patient was prepped and draped in the usual fashion. A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade. This was beveled anteriorly in a lamellar fashion using the crescent knife. Then the anterior chamber was entered with a slit knife. The chamber was deepened with Viscoat. Then a paracentesis at the 3 o'clock position was created using a super sharp blade. A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps. Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves. Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified. I/A proceeded without difficulty using the irrigation/aspiration cannula. The capsule was felt to be clear and intact. The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture. Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally. Maxitrol ointment was instilled into the conjunctival sac. The eye was covered with a double patch and shield, and the patient was discharged." }

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

{ "text_length": 1996 }

{ "text": "REASON FOR REFERRAL:, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the \"early stages of a likely dementia\" and was thereafter terminated from her position as a psychiatric nurse. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning. The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION: ,Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, The patient reported that she had worked as a nurse supervisor for Hospital Center for four years. She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work. She continues to receive some compensation through FMLA hours. She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services. She said that these 90 days are up around the end of November. She said the reason for her dismissal was performance complaints. She said that they began \"as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off. She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays. She described it as a very chaotic and hectic work environment in which she was often putting in extra time. She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time. Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D. He completed a Comprehensive Independent Medical Evaluation on 08/14/2009. She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore. Please note that we do not have copies of any of her work-related correspondence. The patient never received a copy of the neuropsychological evaluation because she was told that it was \"too derogatory.\" A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation. To summarize, the results indicated \"diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history. This suggests that her intellectual functioning has declined.\" It concluded that \"results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy… The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing. The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other. Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits. His neurological examination on 09/23/2009 was unremarkable. The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting. A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions. Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING: ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her. When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills. She also denied any problems with attention and concentration or forgetfulness or memory problems. She continues to independently perform all activities of daily living. She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning. She reported that if her children had noticed anything they definitely would have brought it to her attention. She said that she does not currently have a lawyer and does not intend to return to her previous physician. She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application. Other current symptoms include excessive fatigue. She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia. She also reported having fallen approximately five times within the past year. She said that this typically occurs when she is climbing up steps and is usually related to her right foot \"like dragging.\" Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis. She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body. Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal. She denied any significant medical conditions during childhood. As mentioned, she now has a history of fibromyalgia. She also experiences some restriction in the range of motion with her right arm. MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7. MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon. As mentioned, she was diagnosed with chronic fatigue syndrome in 1991. She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control. She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974. Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007. She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night. She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:, NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs. She drinks two to four cups of coffee per day.,SOCIAL HISTORY: ,The patient was born and raised in North Carolina. She was the sixth of nine siblings. Her father was a chef. He completed third grade and died at 60 due to complications of diabetes. Her mother is 93 years old. Her last job was as a janitor. She completed fourth grade. She reported that she has no cognitive problems at this time. Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. The patient completed a Bachelor of Science in Nursing through State University in 1979. She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. She was married for two years. Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. She has two children ages 43 and 30. Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York. In school, the patient reported obtaining primarily A's and B's. She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. The patient worked for Hospital Center for four years. Prior to that, she worked for an outpatient mental health center for 2-1/2 years. She was reportedly either terminated or laid off and was unsure of the reason for that. Prior to that, she worked for Walter P. Carter Center reportedly for 21 years. She has also worked as an OB nurse in the past. She reported that other than the two instances reported above, she had never been terminated or fired from a job. In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test" }

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

{ "text_length": 12779 }

{ "text": "CLINICAL HISTORY: , This is a 16-year-old man evaluated for sleep difficulties. He states he is \"feeling bad in the mornings\" that he has daytime somnolence and \"whenever I wake up I experience dizziness, weakness, stomachache, loss of appetite, drowsiness, overall sore body and a general feeling of unwell.\" He does state that he has only rarely he got anything suggestive of restless leg syndrome, is unaware of any apnea or like symptoms. He has a mouth breather. He states he wakens up during the night, usually goes to bed at 10 to 11, gets up at 7 to 7:30. In the weekends, he stays up late and sleeps until 1 in the afternoon. He lists sporadic use of melatonin and Benadryl, and Tylenol PM for sleep. His other medicines are Accutane, Nasonex and oxymetazoline. There is no smoking, no alcohol intake. He does have three caffeinated beverages a week. He is 75 inches, 185 pounds, BMI 23.1. He rated himself 4/7 on the Stanford Sleepiness Scale at the onset of the study and 6 on the Epworth Sleeping Scale, said that his night sleep in the lab was characterized by a longer than usual sleep onset latency with more arousals than usual. He woke up feeling equally rested and the only comment he made on the post sleep questionnaire was \"some of the wires\" is the source of problems.,TECHNIQUE: , The study was performed with the following parameters measured throughout the entirety of the recording:,Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.,The record was scored for sleep and the various other parameters in 30-second epochs.,RESULTS: , This study was performed in 61 minutes in duration during which he slept 432 minutes after 19 minutes sleep onset latency; thereafter, he had 10 awakenings for 6 minutes of wakefulness giving him a normal sleep efficiency of 95%. Sleep staging was actually fairly deep and normal for age with 5% stage I, 51% stage II, 22% slow wave sleep and 22% REM. He had 5 REM periods during the night. The first beginning 66 minutes after sleep onset. He did have 63 arousals, giving him a borderline elevated arousal index of 8.8, 16 were driven by limb movements, 41 of unclear origin, 6 from hypopneas.,EEG PARAMETERS: , No abnormalities.,EKG PARAMETERS: , Normal sinus rhythm, mean rate 76, no ectopics noted.,EMG PARAMETERS: , 88 PLMs were noted. There was fairly small excursion with a movement index of 12, only 16 led to arousals with a movement arousal index of 2.2, not considered as a significant feature for sleep fragmentation.,RESPIRATORY PARAMETERS:, Breathing rate in the high teens, reaching as high as 20 in REM. There was really no snoring noted. He slept in all positions and during the night had 9 respiratory events, one was a postarousal central event, the other eight were obstructive hypopneas mean duration 26 seconds, little worse in the supine position where his AHI was 4.7, but overall his AHI was 1.3. This is only a marginal abnormality and is well below the threshold for CPAP intervention.,IMPRESSION:, Largely normal polysomnogram demonstrating very modest obstructive sleep apnea in the supine position and a very modest periodic limb movement disturbance." }

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

{ "text_length": 3318 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP: 117/78. RR: 18. P: 93.,WT: 186 lbs. RAS: 100%.,HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Regular rate and rhythm without murmurs.,EXTREMITIES: No cyanosis, clubbing or edema.,NEURO: Alert and oriented x3. Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN: ,She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm." }

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

{ "text_length": 1983 }

{ "text": "CHIEF COMPLAINT:, Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:, Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:, TURP.,MEDICATIONS:, Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:, None.,FAMILY HISTORY:, Hypertension.,SOCIAL HISTORY:, Significant for about a 20-pack-year tobacco use, quit in 1991. No ethanol use or illicit drug use. He is married. He has one dog at home. He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:, His weight has been steady over the years. Neck collar size is 17½\". He denies any chest pain, cough, or shortness of breath. Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:, A pleasant, obese, African-American male in no apparent respiratory distress. T: 98. P: 90. RR: 20. BP: 156/90. O2 saturation: 97% on room air. Ht: 5' 5\". Wt: 198 lb. HEENT: A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD. CARDIAC: Regular rate and rhythm without any adventitious sounds. CHEST: Clear lungs bilaterally. ABDOMEN: An obese abdomen with active bowel sounds. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Non-focal.,IMPRESSION:,1. Probable obstructive sleep apnea syndrome.,2. Hypertension.,3. Obesity.,4. History of tobacco use.,PLAN:,1. We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2. Encouraged weight loss.,3. Check TSH.,4. Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5. Asked to return to the clinic one week after sleep the study is done." }

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

{ "text_length": 2378 }

{ "text": "PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.," }

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

{ "text_length": 710 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,POSTOPERATIVE DIAGNOSES,1. Desires permanent sterilization.,2. Macrosomia.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:, A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9. There was normal pelvic anatomy, normal tubes. The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip. The abdomen was prepped and draped in a sterile fashion. A Pfannenstiel incision was made and carried sharply down to the level of fascia. The fascia was incised transversely. The fascia was dissected away from the underlying rectus muscles. With sharp and blunt dissection, rectus muscles were divided in midline. The perineum was entered bluntly. The incision was carried vertically with scissors. Transverse incision was made across the bladder peritoneum. The bladder was dissected away from the underlying lower uterine segment. Bladder retractor was placed to protect the bladder. The lower uterine segment was entered sharply with a scalpel. Incision was carried transversely with bandage scissors. Clear amniotic fluids were encountered. The infant was out of the pelvis and was in oblique vertex presentation. The head was brought down into the incision and delivered easily as were the shoulders and body. The mouth and oropharynx were suctioned vigorously. The cord was clamped and cut. The infant was passed off to the waiting pediatrician in satisfactory condition. Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact. Uterus was explored and found to be empty. Uterus was delivered through the abdominal incision and massaged vigorously. Intravenous Pitocin was administered. T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis. Secondary running locking stitch was placed for extra strength to the wound. At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut. Intervening knuckle was excised and passed off the field. The proximal end of the tubal mucosa was cauterized. Cul-de-sac and gutters were suctioned vigorously. The uterus was returned to its proper anatomic position in the abdomen. The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl. Uterus was expressed of its contents. Patient was brought to the recovery room in satisfactory condition. There were no complications. There was 600 cc of blood loss. All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine." }

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

{ "text_length": 3340 }

{ "text": "DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded." }

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

{ "text_length": 1831 }

{ "text": "IMPRESSION: ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity." }

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

{ "text_length": 154 }

{ "text": "ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS: ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003. Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery. Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery. The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen. Her Apgars were 8 at 1 minute and 9 at 5 minutes. At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE: ,The infant has had a basically uncomplicated hospital course. She did not require oxygen. She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus. The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1. She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS: At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT: Head is normocephalic. Eyes are without conjunctival injection. Red reflex is elicited bilaterally. TMs not well visualized. Nose and throat are patent without palatal defect.,NECK: Supple without clavicular fracture.,LUNGS: Clear to auscultation.,HEART: Regular rate without murmur, click or gallop present.,EXTREMITIES: Pulses are 2/4 for brachial and femoral. Extremities without evidence of hip defects.,ABDOMEN: Soft, bowel sounds present. No masses or organomegaly.,GENITALIA: Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL: The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home. She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003. She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good." }

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

{ "text_length": 2781 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:, There were no complications during the procedure.,SPECIMEN: ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS: ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time. The patient had tried nonoperative therapy, which did not assist the patient. The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve. As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated. On initial evaluation, the patient had the symptomology of carpal tunnel syndrome. The patient at the time had the risks, benefits, and alternatives thoroughly explained to her. All questions were answered. No guarantees were given. The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE: ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation. The patient was then given sedation. Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine. The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray. Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia. A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament. This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released. The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt. The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed. Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric. Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times. Palmar fascia was released both proximally and distally as well as the transverse carpal ligament. Direct palpation of the carpal canal demonstrated a full and complete release. Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression. Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch. Xeroform was then applied to the incision. A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications." }

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

{ "text_length": 3661 }

{ "text": "SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15. Cranial nerves II to XII are grossly intact. Motor exam demonstrates 5/5 strength in all four extremities. Sensation is intact to light touch, pain, temperature, and proprioception. Cerebellar exam is intact. Gait is normal and tandem on heels and toes. Speech is appropriate. Judgment is intact. Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass. Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. He agrees that he will be n.p.o. after mid night on Wednesday night. He is sent for preoperative assessment with the Anesthesiology tomorrow morning. He has undergone vocational rehab assessment." }

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

{ "text_length": 1846 }

{ "text": "HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:, The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. There were come concentric rings present. There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach are normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. Adverse reactions: None.,FINAL IMPRESSION: ,Esophageal changes suggestive of eosinophilic esophagitis. Biopsies throughout the length of the esophagus were obtained for microscopic analysis. There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract." }

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

{ "text_length": 1633 }

{ "text": "CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM:" }

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

{ "text_length": 67 }

{ "text": "PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:, A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained. The patient was noted to have irregular contractions. She was given 1 dose of subcutaneous terbutaline which resolved her contraction. A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation. There was noted to be adequate fluid. Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained. Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring. Following successful external cephalic version, the patient was placed on continuous external fetal monitoring. She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version. She did not have regular contractions and therefore she was felt to be stable for discharge to home. She was given appropriate labor instructions." }

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

{ "text_length": 1292 }

{ "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": " Letters", "score": 1 } ]

{ "text_length": 1455 }

{ "text": "EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body. Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament. Medial capsule sprain with associated strain of the vastus medialis oblique muscle. There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica." }

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

{ "text_length": 2311 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS: ,10 mL.,FLUIDS RECEIVED:, 300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee. Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified. Once he was anesthetized, IV antibiotics were given. The dorsal hood was retracted and cleansed. He was then sterilely prepped and draped. Stay suture of #4-0 Prolene was then placed in the glans. His urethra was calibrated to 10-French bougie-a-boule. We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum. Byers flaps were also marked. Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis. On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage. Once this was done, an electrocautery was used for hemostasis were then used. A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee. We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture. Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight. We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate. We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings. Using the curved iris scissors, we then elevated the wings even further. Again, electrocautery was used for hemostasis. An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture. There were two areas of coverage with the tissue flap relocation from the glanular wings. The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl. Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl. Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline. The extra dorsal hood tissue of preputial skin was then excised. An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline. The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself. At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing. Telfa and the surgical eye tape was then used for the final dressing. IV Toradol was given. The patient tolerated the procedure well and was in stable condition upon transfer to recovery room." }

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

{ "text_length": 3791 }

{ "text": "REASON FOR ADMISSION:, Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:, The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding. He is otherwise healthy. He tried to insert a marble in his penis four days ago. He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble. Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there. He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has. Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out. He was bleeding so much that he started dripping to the sides of his legs. So, he was brought to the hospital. Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood. He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis. The marble also still can be felt underneath the skin. There is no urethral bleeding. He did urinate today without difficulty, without hematuria or dysuria. There is pain in the lacerations. No erythema in the skin or swelling in the penis and no other injuries. He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: ,Tonsillectomy.,MEDICATION: , He took only ibuprofen. No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY: ,He has been in detention for two months for immigration problems. No drugs. No alcohol. No smoking. He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL: The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS: Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT: Sclerae nonicteric. Pupils reactive to light. Nostrils are normal. Oral cavity is clear.,NECK: Supple. Trachea midline. No JVD.,LUNGS: Clear to auscultation bilaterally.,HEART: Normal S1 and S2. No murmurs or gallops.,ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds.,EXTREMITIES: Pulses strong bilaterally. No edema.,GENITAL: Testicles appear normal. The penis shaft has two lacerations on both sides, one of them is bleeding. They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side. The one on the right side is bleeding much more than the other one. There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis. There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:, White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000. Coags unremarkable. Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7. Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis. No other injuries that can be seen and no other evidence of secondary bacterial infection at this time. The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1. The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2. The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3. Prophylactic antibiotics to prevent infection.,4. He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that. This will be monitored.,5. Monitor H&H to determine if he needs any transfusion at this time. He does not need that.,6. IV fluid for hydration and volume resuscitation at this time.,7. Pain management.,8. Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this." }

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

{ "text_length": 5324 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:, Local.,FINDINGS: , This patient had previously had excision of hydradenitis. However, she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis. This now is controlled and it was found to be suitable for excision. There was an area in each axilla which needed to be excised.,PROCEDURE: , Under local infiltration and after routine prepping and draping, an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis. This wound was then irrigated with saline. The deeper layers were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 5-0 nylon.,Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side. This appeared to encompass all of the active area of hydradenitis.,The needle counts were all correct. No intraoperative complications were encountered. Dressings were applied, and the patient was returned to the recovery room in satisfactory condition." }

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

{ "text_length": 1277 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital." }

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

{ "text_length": 4329 }

{ "text": "PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PROCEDURE IN DETAIL: , The ultrasound was used to localize the left femoral vein and to confirm it's patency and course. The left inguinal area was then prepped and draped in a sterile manner. The overlying soft tissues were anesthetized with 1% plain lidocaine. Under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced. This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself. Finally, the multilumen catheter itself was inserted over the guidewire. Once the catheter was fully inserted, the guidewire was completely withdrawn. Placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied. He tolerated the procedure very well, without complications." }

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

{ "text_length": 1190 }

{ "text": "NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized. A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic. A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome. A 5- to 5.5-mm anterior capsulorrhexis was created. The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag. The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique. Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification. Peripheral cortex was removed with the irrigation and aspiration handpiece. The posterior capsule was polished. The capsular bag was expanded with viscoelastic. The implant was inspected under the microscope and found to be free of defects. The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag. The trailing haptic was positioned with the cartridge system. Residual viscoelastic was removed from the anterior chamber and from behind the implant. The corneal wound was hydrated with balanced salt solution. The anterior chamber was fully re-formed through the side-port incision. The wound was inspected and found to be watertight. The intraocular pressure was adjusted as necessary. The lid speculum was removed. Topical Timoptic drops, Eserine and Dexacidin ointment were applied. The eye was shielded. The patient appeared to tolerate the procedure well and left the operating room in stable condition. Followup appointment is with Dr. X on the first postoperative day." }

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

{ "text_length": 2139 }

{ "text": "SUBJECTIVE: ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. He appears confused and depressed at times. Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past. He will attend social skills program in the summer. ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis. There is lessening of tremoring in both hands since discontinuation of Zoloft. He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:, Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed. I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis. Parents will call me in two weeks. I will see him for medication review in four weeks. Mother signed informed consent. I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal. Combination of medication and behavioral intervention is recommended." }

[ { "label": " Psychiatry / Psychology", "score": 1 } ]

{ "text_length": 1642 }

{ "text": "OPERATION:," }

[ { "label": " Pain Management", "score": 1 } ]

{ "text_length": 11 }

{ "text": "CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative. Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:, I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition." }

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

{ "text_length": 1975 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:, None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well." }

[ { "label": " ENT - Otolaryngology", "score": 1 } ]

{ "text_length": 1633 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1. Right ruptured ectopic pregnancy with hemoperitoneum.,2. Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy." }

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

{ "text_length": 1700 }

{ "text": "PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure. A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine. A dorsal slit was made, and the prepuce was dissected away from the glans penis. A ** Gomco clamp was properly placed for 5 minutes. During this time, the foreskin was sharply excised using a #10 blade. With removal of the clamp, there was a good cosmetic outcome and no bleeding. The child appeared to tolerate the procedure well. Care instructions were given to the parents." }

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

{ "text_length": 835 }

{ "text": "REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit." }

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

{ "text_length": 2336 }

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

{ "text_length": 1080 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:, General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:, Stable to PACU.,PROCEDURE: Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure. Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction. Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction. The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right. Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction. It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered. On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction. Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur. Tooth was then luxated from the socket. The flaps were then closed on both quadrants with 3-0 gut sutures. The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000. Upon completion of the procedure, the throat pack was removed. The pharynx was suctioned. An oral gastric tube was passed and small amount of stomach contents were suctioned. The patient was then extubated and taken to PACU in stable condition." }

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

{ "text_length": 2452 }

{ "text": "EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:, Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1. No evidence for acute fracture or subluxation.,2. Mild degenerative changes.,3. Probable left simple renal cyst.," }

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

{ "text_length": 904 }

{ "text": "POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbronchial biopsies.,COMPLICATIONS:, None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION: ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:, After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications." }

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

{ "text_length": 4075 }

{ "text": "Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices \"told him to do good things\". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was \"very stressful\". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and \"nervous breakdown\".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed." }

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

{ "text_length": 5641 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to \"pop into place.\" He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,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: Blood pressure 130/70" }

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

{ "text_length": 2357 }

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

{ "text_length": 1169 }

{ "text": "PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE: ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA: ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None. Post-fixation x-rays, nonalignment, no new changes. Post-fixation neurologic examination normal.,CLINICAL HISTORY: ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:, The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine. A large PMT crown was brought in and fixed to the skull with pins under local anesthetic. Excellent fixation achieved. It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck. The vest was brought in from the front as well and connected. Head was tilted appropriately, slightly extended, and in the midline. All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout. X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days. Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery. She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family." }

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

{ "text_length": 3108 }

{ "text": "REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:, Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3. Pupils equal and reactive. EOMs are full. Motor is 5 out of 5. She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus. There is no evidence of clonus. There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord. I had a thorough discussion with the patient and her parents. I have recommended a repeat MRI scan. The prescription was given today. MRI of the lumbar spine was just completed. I would like to see her back in clinic. We did discuss the possible symptoms of this tethering." }

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

{ "text_length": 1310 }

{ "text": "PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy." }

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

{ "text_length": 635 }

{ "text": "CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual \"lump\" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS: ,1. Lovenox 60 mg subcutaneously q.12h. initiated.,2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3. Protonix 40 mg intravenous (IV) daily.,4. Vicodin p.r.n.,5. Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY: ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY: ,Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY: ,The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION: ,GENERAL: Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN: Mild facial acne.,HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS: Clear to auscultation with an occasional productive cough.,ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA: ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.,ASSESSMENT: , 1. Newly diagnosed high-risk acute lymphoblastic leukemia.,2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3. Probable chronic left epididymitis.,PLAN: , 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3. Ultrasound/Doppler of the testicles.,4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.," }

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

{ "text_length": 7544 }

{ "text": "PROCEDURE PERFORMED:, PICC line insertion.,DESCRIPTION OF PROCEDURE:, The patient was identified by myself on presentation to the angiography suite. His right arm was prepped and draped in sterile fashion from the antecubital fossa up. Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. A guidewire was then threaded through the vein and advanced without difficulty. An introducer was then placed over the guidewire. We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. It was very tortuous area. We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. Decision was made at that point then to just do a midline catheter. The catheter was cut to 20 cm, then we inserted back to the introducer. The introducer was removed. The catheter was secured by two #3-0 silk sutures. Appropriate imaging was then taken. Sterile dressing was applied. The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor. We may make another attempt in the near future using a different approach.," }

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

{ "text_length": 1513 }

{ "text": "CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest. Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region. There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm. A subcarinal lymph node is enlarged also. It measures 6 x 2 cm. Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura. There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm. There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit. The liver parenchyma is normal without evidence of any dominant masses. The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1. Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2. Extensive mediastinal adenopathy as described above.,3. No lesion seen within the left lung at this time.,4. Supraclavicular adenopathy." }

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

{ "text_length": 1683 }

{ "text": "REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time." }

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

{ "text_length": 1577 }

{ "text": "EXAM:, Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS: ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained. Ultrasound demonstrates free fluid in the abdomen. The area of interest was localized with ultrasonography. The region was sterilely prepped and draped in the usual manner. Local anesthetic was administered. A 5-French Yueh catheter needle combination was taken. Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle. A total of approximately 5500 mL of serous fluid was obtained. The catheter was then removed. The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above." }

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

{ "text_length": 825 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table. The right lower extremity was protectively padded. The left leg was propped with multiple blankets. The hip was then prepped and draped in the usual manner. A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues. Hemostasis was achieved utilizing electrocautery. Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly. The external rotators were identified after removal of the trochanteric bursa. Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line. They were then reflected distally. The capsule was then opened in a T-fashion utilizing the cutting cautery. Fraction hematoma exuded from the hip joint. The cork screw was then impacted into the femoral head and it was removed from the acetabulum. Bone fragments were removed from the neck and acetabulum. The acetabulum was then inspected and noted to be free from debris. The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur. The T-handle broach was then passed down the canal. The canal was then sequentially broached up to a medium broach. The calcar was then plained with the hand plainer. The trial components were positioned into place. The medium component fit fairly well with the medium 28 mm femoral head. Once the trial reduction was performed, the hip was taken through range of motion. There was physiologic crystalling with longitudinal traction. There was no tendency towards dislocation with flexion of the hip past 90 degrees. The trial implants were then removed. The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry. The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit. The implant was then impacted into place. The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup. The acetabulum was once again inspected, was free of debris. The hip was reduced. It was taken through full range of motion. There was no tendency for dislocation. The wound was copiously irrigated with gentamicin solution. The capsule was then repaired with interrupted #1 Ethibond suture. External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch. The wound was once again copiously irrigated with gentamicin solution and suctioned dry. Gluteus fascia was approximated with interrupted #1 Ethibond. Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples. A bulky dressing was applied to the wound. The patient was then transferred to the hospital bed, an abductor pillow was positioned into place. Circulatory status was intact to the extremity at completion of the case." }

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

{ "text_length": 3684 }

{ "text": "FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home. Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS: ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT: Headaches, vision changes, dizziness, and sore throat. GI: Difficulty swallowing. Musculoskeletal: She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis. Respiratory: Shortness of breath and cough. Cardiac: Chest pain and swelling in her feet and ankle. Psychiatric: Anxiety and depression. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Genital: Negative and noncontributory.,PHYSICAL EXAMINATION:, On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds. BP 138/78, pulse is 64. General: A well-developed, well-nourished female, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, she does have some poor dentition. She does say that she needs some of her teeth pulled on her lower mouth. Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation. EOMs are full bilaterally. Pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry. Normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. She does have some tremoring of her bilateral upper arms as she said. Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted. She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left. Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles. No ankle clonus is elicited. Hoffmann's is negative bilaterally. Sensation is intact. She ambulates with slow short steps. No spastic gait is noted. She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane. She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today. She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level. No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:, We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm. She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available. She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery. All questions and concerns were addressed with her. Warning signs and symptoms were gone over with her. If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled. I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well. Case was reviewed and discussed with Dr. L." }

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

{ "text_length": 4809 }

{ "text": "ALLOWED CONDITIONS:, 726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:, 354.2 right cubital tunnel syndrome.,EMPLOYER:, ABCD, ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above. I obtained her history from company medical records and performed an examination. She is a 38-year-old laborer who states that she was injured on April 26, 2006, which according to the FROI (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars). She denies having any symptoms prior to the accident April 26, 2006. She is right handed. She used a tennis elbow brace, hand exercises, physical therapy, and Vicodin. She received treatment from Dr. X and also Dr. Y,DIAGNOSTIC STUDIES:, June 27, 2006, EMG and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome. No evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow. January 29, 2007, EMG right upper extremity was normal and there was a normal nerve conduction velocity. At the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain. The pain was accentuated by gripping or opening the jar. She is taking four Aleve a day and currently does not have any other treatment.,RECORDS REVIEWED: , Injury and illness incident report, US Healthworks records; Z physician review; Y office notes; X office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,EXAMINATION: , Examination of her right elbow revealed no measurable atrophy of the upper arm. She was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve. I did not detect subluxation of the ulnar nerve with flexion and extension. With this, she was extremely tender in this area. There is no instability of the elbow. Range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination. The elbow flexion test was positive. There is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics. There was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger. There was no wasting of the intrinsics. No clawing of the hand. Examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees. She was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist. Wrist flexion causes paresthesias on the right ring and small fingers. Grasp was weak. There was no sign of causalgia, but no measurable atrophy of the forearm. No reflex changes.,QUESTION:, Ms. Xxxxx has filed an application of additional allowance of right cubital tunnel syndrome. Based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER:, Yes. She has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger. I did not find the subluxation of the ulnar nerve with flexion and extension with Dr. X did previously find on his examination.,QUESTION: , If you find these conditions exist, are they a direct and proximate result of April 26, 2006, injury?,ANSWER: , Yes. Repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which Dr. X objectively identified on his examination. Therefore, I believe it is a direct and proximate result of April 26, 2006, injury.,QUESTION: , Do you find that Ms. Xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,ANSWER: , No.,QUESTION:, In addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to Ms. Xxxxx's condition?,ANSWER: , It is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,QUESTION: ," }

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

{ "text_length": 4620 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:, Spinal/epidural with good effect.,FINDINGS: ,Delivered vigorous male infant from cephalic presentation. Apgars 9/9. Birth weight 6 pounds 14 ounces. Infant suctioned with a bulb upon delivery of the head and body. Cord clamped and cut and infant passed to pediatric team present. Complete placenta manually extracted intact with three vessel cord. Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision. In addition, the bladder was involved in adhesion mass complex. A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions. These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall. Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries. Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT: ,Per anesthesia records. Urine cleared postoperatively.,IV FLUIDS: ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia. She was prepped and draped in the usual manner for repeat cesarean section. A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar. This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife. This incision was extended laterally with Mayo scissors. Dense fibromuscular layer was encountered from the patient's previous surgeries. Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision. Fascia was previously separated superiorly and inferiorly from the muscular layer. A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus. Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall. This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall. Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall. These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection. This was successfully done without anterior entry into the bladder. Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus. The uterus was then incised using a sharp knife and low transverse incision. This was extended with bandage scissors. The infant was delivered easily from a cephalic presentation. Bulb suction was done following delivery of the head and body. The cord clamped and cut and the infant passed to pediatric team present. Cord segment and cord blood was obtained. Complete placenta manually extracted intact with three vessel cord. Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces. Complete placenta with three vessels retrieved. Uterus was exteriorized from the abdominal cavity. Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining. Pennington clamps placed at the uterine incision angles and the inferior incision lip. A #1 chromic suture closed the uterus in running continuous interlocking closure. Good hemostasis upon completion of the closure. Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots. The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion. This was closed with chromic suture in a running continuous interlocking closure with good hemostasis. Attention was then focused on the bilateral tubal ligation. Babcock clamp placed in the mid fallopian tube and elevated. Cautery was used to make a window in the avascular segment of the mesosalpinx. Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed. The ligated proximal and distal stumps were then cauterized with Bovie cautery. This tubal ligation procedure was done in a bilateral fashion. Upon completion of tubal ligation, uterus was returned to the abdominal cavity. Left and right gutters examined and found to be clean and dry. Evaluation of the low uterine segment incision revealed continued hemostasis. Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done. Interceed was then placed on the low uterine incision and the low anterior uterine aspect. The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures. Irrigation of the muscular layer with good hemostasis noted. The fascia was closed with #1 Vicryl in a running continuous closure. Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery. The skin was closed with staples." }

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

{ "text_length": 6286 }

{ "text": "DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression." }

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

{ "text_length": 1494 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:, Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1. Removal of antibiotic spacer.,2. Revision total hip arthroplasty.,IMPLANTS,1. Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2. Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3. A 32-mm femoral head with a +0 neck length.,ANESTHESIA: ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:, None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:, The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma. This subsequently became infected. She has undergone removal of this prosthesis and placement of antibiotic spacer. She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room by anesthesia personnel. She was placed supine on the operating table. A Foley catheter was inserted. A formal time out was obtained in identifying the correct patient, operative site. Preoperative antibiotics were held for intraoperative cultures. The patient was placed into the lateral decubitus position with the right side up. The previous surgical incision was identified. The right lower extremity was prepped and draped in standard fashion. The old surgical incision was reopened along its proximal extent. Immediately encountered was a large amount of fibrous scar tissue. Dissection was carried sharply down through this scar tissue. Soft tissue plains were extremely difficult to visualize due to all the scarring. There was no native tissue to orient oneself with. We carried our dissection down through the scar tissue to what seemed to be a fascial layer. We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter. Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed. This was used as a landmark to orient remainder of the dissection. The antibiotic spacer was exposed and followed distally to expose the proximal femur. Dissection was continued posteriorly and proximally to expose the acetabulum. A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure. Once improved visualization was obtained, the antibiotic spacer was removed from the femur. This allowed further improved visualization of the acetabulum. The acetabulum was filled with soft tissue debris and scar tissue. This was removed with sharp excision with a knife as well as with a rongeur and a Bovie. Once soft tissue was removed, the acetabulum was reamed. Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell. The 50 mm shell was trialed and had good stability and fit. Attention was then turned to continue preparation of the femur. The canal was then debrided with femoral canal curettes. Some fibrous tissue was removed from the canal. The length of the femoral stem was then checked with this canal curette in place. Following x-rays, we prepared to begin reaming the femur. This femur was reamed over a guide rod using flexible reaming rods. The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem. The stem was selected and initially size A body was placed in trial. The body was too tight proximally to fit. The proximal canal was then reamed for a size AA body. A longer stem with an anterior bow was selected and a size AA trial was assembled. This fit nicely in the canal and had good fit and fill. Intraoperative radiographs were obtained to determine component position. Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur. The remainder of the trial was then assembled and the hip was relocated and trialed. Initially, it was found to be unstable posteriorly. We changed from a 10 degree lip liner to 20 degree lip liner. Again, the hip was trialed and found to be unstable posteriorly. This was due to reversion of the femoral component. As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion. The stem was extracted and retrialed. Improved stability was obtained and we decided to proceed with the real components. A 20 degree liner was inserted into the acetabular shell. The real femoral components were assembled and inserted into the femoral canal. Again, the hip was trialed. The components were found to be in relative retroversion. The real components were then backed down and the neck was placed in the more anteversion and reinserted. Again, the stem attempted to follow in the relative retroversion. Along with this time, however, it was improved from previous attempts. The femoral head trial was placed back on the components and the hip relocated. It was taken to a range of motion and found to have improved stability compared to previous trialing. Decision was made to accept the component position. The real femoral head was selected and implanted. The hip was then taken again to a range of motion. It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation. The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage. Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion. A Hemovac drain was placed deep to the fascial layer. The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin. An incisional VAC was then placed over the wound as well. Sponge and needle counts were correct at the close of the case.,DISPOSITION:, The patient will be weightbearing as tolerated with posterior hip precautions." }

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

{ "text_length": 6156 }

{ "text": "PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above. The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some hemorrhoids. The scope was then removed. The patient tolerated the procedure well.,RECOMMENDATIONS: ,Repeat colonoscopy in three years." }

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

{ "text_length": 1418 }

{ "text": "PROCEDURE:,: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges. The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant. The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. An intraoperative cholangiogram was obtained. This revealed good flow through the cystic duct and into the common bile duct. There was good flow into the duodenum without any filling defects. The hepatic radicals were clearly visualized. The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site. The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision. The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case." }

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

{ "text_length": 3129 }

{ "text": "PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3. Right suboccipital craniectomy and excision of tumor.,4. Microtechniques for all the above.,5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady." }

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

{ "text_length": 6435 }

{ "text": "CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease.,PAST SURGICAL HISTORY:, Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1. Metoprolol 100 mg b.i.d.,2. Diltiazem 120 mg daily.,3. Hydrocodone 10/500 mg p.r.n.,4. Pravastatin 40 mg daily.,5. Lisinopril 20 mg daily.,6. Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection.,LABORATORY EXAM:, Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:, Bladder cancer.,PLAN: ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan." }

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

{ "text_length": 5508 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:, Excision dorsal ganglion, right wrist.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:, minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg. A transverse incision was made over the dorsal ganglion. Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto. Care was taken to protect ligament integrity. Reactive synovium was then removed using soft tissue rongeur technique. The wound was then infiltrated with 0.25% Marcaine. The tendons were allowed to resume their normal anatomical position. The skin was closed with 3-0 Prolene subcuticular stitch. Sterile dressings were applied. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well." }

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

{ "text_length": 1470 }

{ "text": "SPECIMENS:,1. Pelvis-right pelvic obturator node.,2. Pelvis-left pelvic obturator node.,3. Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1. Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2. No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3. Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled \"right pelvic obturator lymph nodes\" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm. There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm. The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled \"left pelvic obturation lymph nodes\" consists of an adipose tissue measuring 4 x 2 x 1 cm. There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm. The entire specimen is cut into 1 cm. The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled \"prostate\" consists of a prostate. It measures 5 x 4.5 x 4 cm. The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration. External surface also shows tumor induration especially in right side. External surface is stained with green ink. The cut surface shows diffuse tumor induration especially in right side. The tumor appears to extend to excision margin. Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node. There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate. Gleason's score 9 (5+4). The tumor shows extension to periprostatic tissue as well as margin involvement. Seminal vesicle attached to prostate tissue shows tumor invasion. Dr. XXX reviewed the above case. His opinion agrees with the above diagnosis.,SUMMARY:,A. Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B. There is lymph node metastasis (N1).,C. Distant metastasis cannot be assessed (MX).,D. Excision margin is positive and there is tumor extension to periprostatic tissue." }

[ { "label": " Lab Medicine - Pathology", "score": 1 } ]

{ "text_length": 2439 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE: ,ICU. Room #164.,ANESTHESIA/SEDATION:, Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time." }

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

{ "text_length": 3263 }

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

{ "text_length": 2550 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a 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. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital." }

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

{ "text_length": 7124 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:, Exam under anesthesia. Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:, Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed. She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition." }

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

{ "text_length": 1922 }

{ "text": "XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma. I examined Mrs. ABC initially on MM/DD/YYYY. At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache. She reports a family history of glaucoma in her mother, but is unsure of the specific kind. Her past ocular history has been fairly unremarkable. As you know, she has a history of non-insulin dependent diabetes. She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me. She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses. Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m. Pupillary reactions, confrontational visual fields, and ocular motility were normal. The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure. I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent. I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes. Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs. Her intraocular pressures have remained stable. I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care. If I can provide any additional information or be of further service, do let me know.,Sincerely,," }

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

{ "text_length": 2274 }

{ "text": "CHIEF COMPLAINT: ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:, This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well. The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do. The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house. The patient states that she just simply felt funny and does not give any more specific details than this. The patient denies any pain at any time. She did not have any shortness of breath. No nausea or vomiting. No generalized weakness. The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go. The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved. The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF. The patient was discharged home after evaluation in the emergency room. The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician. The patient denies having any other symptoms today. The patient denies any fever or chills. Has not had any recent weight change. HEENT: The patient denies any headache. No neck pain. No rhinorrhea. No sinus congestion. No sore throat. No any vision or hearing change. No eye or ear pain. CARDIOVASCULAR: The patient denies any chest pain. RESPIRATIONS: No shortness of breath. No cough. No wheeze. The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No change in the bowel movements. There has not been any diarrhea or constipation. No melena or hematochezia. GENITOURINARY: No dysuria, hematuria, urgency, or frequency. MUSCULOSKELETAL: No back pain. No muscle or joint aches. No pain or abnormalities to any portion of the body. SKIN: No rashes or lesions. NEUROLOGIC: The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days. The patient denies any dizziness at this time. No syncope or no near-syncope. The patient denies any focal weakness or numbness. No speech change. No difficulty with ambulation. The patient has not had any vision or hearing change. PSYCHIATRIC: The patient denies any depression. ENDOCRINE: No heat or cold intolerance.,PAST MEDICAL HISTORY:, COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:, Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear sclerae and cornea bilaterally. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx are normal without any sign of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. No cervical lymphadenopathy. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. The patient does have +1 bilateral lower extremity edema. RESPIRATIONS: The patient has coarse breath sounds bilaterally, but no dyspnea. Good air movement. No wheeze. No crackles. The patient speaks in full sentences without any difficulty. The patient does not exhibit any retractions, accessory muscle use or abdominal breathing. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy. MUSCULOSKELETAL: No abnormalities noted to the back, arms or legs. SKIN: No rashes or lesions. NEUROLOGICAL: Cranial nerves II through XII are intact. Motor is 5/5 and equal to bilateral arms and legs. Sensory is intact to light touch. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her. The patient has normal mood and affect. HEMATOLOGIC AND LYMPHATIC: There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture. There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08. CBC has no specific abnormalities of issue. Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20. The rest of the values are normal and unremarkable. LFTs are all within normal limits. Cardiac enzymes are all within normal limits. Digoxin level is therapeutic at 1.6. Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago. CAT scan of the head did not identify any acute abnormalities. I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day. I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past. The neighbor is XYZ and he says that he checks on her three times a day every day. ABC is the patient's son and although he lives out of town he calls and checks on her every day as well. He states that he spoke to her yesterday. She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician. She sounded her usual self to him. Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him. He states that he will be able to check on her tomorrow as well. Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements. The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well. The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1. EARLY DEMENTIA.,2." }

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

{ "text_length": 8545 }

{ "text": "PROBLEM LIST:,1. Acquired hypothyroidism.,2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. Diabetes mellitus.,4. Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1. Levothyroxine 125 micrograms p.o. once daily.,2. CPAP.,3. Glucotrol.,4. Avandamet.,5. Synthroid.,6. Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI. She is not reporting polyuria, polydipsia or polyphagia. She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL: She is an overweight, very pleasant woman, in no acute distress. VITAL SIGNS: Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. NECK: Reveals well healed surgical scar in the anteroinferior aspect of the neck. There is no palpable thyroid tissue noted on this examination today. There is no lymphadenopathy. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 is auscultated. EXTREMITIES: Deep tendon reflexes 2+/4 without a delayed relaxation phase. No fine resting tremor of the outstretched upper extremity. SKIN, HAIR, AND NAILS: All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following: Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1. Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2. Plan to continue following thyroglobulin levels.,3. Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4. Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5. Plan today is to repeat her thyroid function studies. This case was discussed with Dr. X and the recommendation. We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less. Therefore, labs have been drawn. We plan to see the patient back in approximately 6 months or sooner. A repeat body scan will not been done, the one in 03/06 was negative." }

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

{ "text_length": 3288 }

{ "text": "POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed. The patient has been ambulating without difficulty. The patient is still NPO. The patient denies any new symptomatology from 6/10/2009. The patient has complaints of incisional tenderness. The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS: Afebrile now. Other vital signs are stable.,GU: Urinating through Foley catheter.,ABDOMEN: Soft, negative rebound.,EXTREMITIES: Without Homans, nontender.,BACK: Without CVA tenderness.,GENITALIA: Vagina, slight spotting. Wound dry and intact.,ASSESSMENT:, Normal postoperative course.,PLAN:,1. Follow clinically.,2. Continue present therapy.,3. Ambulate with nursing assistance only.," }

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

{ "text_length": 847 }

{ "text": "PREOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2. Microscope.,3. Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4. Eagle titanium plate from C3 to C6.,5. Jackson-Pratt drain placement.,6. Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: ,None.,COUNTS: , Correct.,SPECIMENS SENT: ,None.,CLINICAL HISTORY: ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling. He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy. I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly. The patient had worst disease at level C3-C4, C4-C5, and C5-C6. The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side. I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall. Conservative management was not an option. The patient was preoped and consented, and was medically cleared. I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family. The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient. An informed consent was obtained from the patient as such. He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the OR, intubated, and given a general anesthetic. Intubation was done under C-spine precautions. The patient received preoperative vancomycin and Decadron. He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped. All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine. Prominent osteophyte at C5-C6 was noted, lesser at C4-C5. Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went. I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord. Worst findings at C3-C4 followed C5-C6 and then C4-C5. Excellent thecal sac decompression was achieved and foraminal decompression was also achieved. With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant. This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time. I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis. This took literally half-an-hour to an hour and added to the complexity and difficulty of this case. Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution. These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position. Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6. Fourteen millimeter screws were used; all the screws were tightened and torqued. The patient's bone quality was poor, but the screws did torque appropriately. I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar. Decision was made to start the closure. So, I closed the platysma with 3-0 Vicryl and used staples for the skin. A simple Primapore or Medpore dressing was applied. The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side. He had done well from the surgery. Blood loss was 350 cc. All instrument, needle, and sponge counts were correct. No complications, no change in intraoperative monitoring. No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis. The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity. I will keep him on Decadron and keep the collar on. I do not think there is need for halo rest. We will be obtaining formal C-spine films in the morning. Prognosis is guarded but favorable at this time." }

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

{ "text_length": 6164 }

{ "text": "PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position. Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. This would result in an elevation of the nipple-areolar complex with transposition. The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. Hemostasis was achieved with electrocautery. After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture. Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing. The patient tolerated the procedure well. The patient was returned to recovery room in satisfactory condition." }

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

{ "text_length": 2093 }

{ "text": "DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:, The patient is appropriate. She is well dressed and oriented x3. She still smells of some cigarette smoke. Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:, After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. A total of 400 units of Botox is anticipated. The procedure is being scheduled. The patient's medications are refilled. She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria." }

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

{ "text_length": 1704 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,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 a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. 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 into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear \"S\"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition." }

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

{ "text_length": 5138 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extremity was then prepped and draped in the usual manner. A sterile tourniquet was placed on the proximal aspect of the right upper extremity. The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg. Tourniquet time was 74 minutes. A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. Hemostasis was achieved utilizing electrocautery. Subcutaneous fat was separated and the skin flaps elevated. The _________ was identified. It was incised. The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. There was some serosanguineous fluid from the previous rupture. This area was suctioned clean. The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. At this point, the #2 fiber wire was then passed through the tendon. Two fiber wires were utilized in a Krackow-type suture. Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. The radial tuberosity was palpated. Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. A skin incision was made over this area. Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa. The tails of the fiber wire suture were grasped and pulled down through the second incision. At this point, they were placed to the side. Attention was directed at exposure of the radial tuberosity with a forearm fully pronated. The tuberosity came into view. The margins were cleared with periosteal elevator and sharp dissection. Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. Three small drill holes were then placed along the margin for passage of the suture. The area was then copiously irrigated with gentamicin solution. A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. The suture was tied over the bone islands. Both wounds were then copiously irrigated with gentamicin solution and suctioned dry. Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples. The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples. Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia. A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. Tourniquet was inflated prior to application of the splint. Circulatory status returned to the extremity immediately. The patient was awakened. He was rather boisterous during his awakening, but care was taken to protect the right upper extremity. He was then transferred to the recovery room in apparent satisfactory condition." }

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

{ "text_length": 3823 }

{ "text": "PREOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:, General.,FINDINGS:, The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There was a stone impacted in the cystic duct with the gallbladder. The gallbladder contained numerous stones which were small. With the stone impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:, Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled." }

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

{ "text_length": 2122 }

{ "text": "3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470." }

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

{ "text_length": 2303 }

{ "text": "TITLE OF OPERATION:, A complex closure and debridement of wound.,INDICATION FOR SURGERY:, The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain. There is no evidence of fevers. CRP was normal. Shunt CT were all normal. The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion. Next, working on the fistula, this was elliptically excised. Once this was excised, this was followed down to the fistulous tract, which was completely removed. There was no CSF drainage. The catheter was visualized, although not adequately properly. Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied. The patient was reversed, extubated and transferred to the recovery room in stable condition. Multiple cultures were sent as well as the tracts sent to Pathology. All sponge and needle counts were correct." }

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

{ "text_length": 1529 }

{ "text": "NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.,Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.,2. Left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures." }

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

{ "text_length": 2919 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION: ,1. The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2. Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily. She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention. All questions answered." }

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

{ "text_length": 1280 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well." }

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

{ "text_length": 3931 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1. Bilateral myringotomies.,2. Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:, None.,FINDINGS: ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:, With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. Bilateral inferior radial myringotomies were performed, first on the right and then on the left. Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side. Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered." }

[ { "label": " ENT - Otolaryngology", "score": 1 } ]

{ "text_length": 1395 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE: ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour. He was on a curve and lost control. He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding. There were no other injuries. He was treated in Kentucky. A close reduction was performed and splint applied. Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan. The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight. The patient showed up in the emergency department where a CT scan was asked to be performed. This was performed and reviewed. The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days. At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches. The patient was x-rayed in the office. He had lost some of his reduction. Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally. It appeared as an abduction type injury with minimal rotation. This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type. The syndesmosis appeared to be intact. This appeared as an AO type B fracture. However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted. CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner. A posterior Tillaux fragment appeared to be separate. However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient. He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness. We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan. We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery. We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness. Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly. We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions. We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally. He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula. We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction. He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space. With this, the patient understood that the hardware may necessitate removal as well in the future. We discussed hardware irritation. We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly. With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:, The patient was brought to operating theater and given successful general anesthetic. His right leg was prepped and draped in the usual fashion. Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction. It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up. However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue. The superficial peroneal nerve was seen and this was avoided. The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally. The fracture was seen. The fracture was elevated and medialized and de-rotated. The anterior portion of the distal fibula was significantly comminuted with defect. The posterior aspect was still intact. However, there were multiple fracture lines demonstrating a crush-type injury. This was reduced manually. At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon. No sharp dissection was performed. The posterior malleolar fragment was palpated with the distal fibula reduced. The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus. This was taken only through subcutaneous tissue. The saphenous vein was found, dissected out. Its branches were cauterized. Penrose drain was placed around this.,Dissection was undertaken. The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides. Next, the towel clip was used. Ends were freshened up using irrigation. The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws. Anatomic reduction was gained. X-rays were taken showing excellent anatomic reduction. Next, attention was drawn towards the fibula. Standard 6-hole one-third tubular plate was applied to this. Again, this was more of a transverse impacted fracture. Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction. Screws were placed. It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled. They were double-checked. Screws had excellent purchase and were tightened up. At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond. This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used. Finger was placed on this fragment and the pin was advanced even before the finger. X-ray views could show the posterior cortex and location of the pin. This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed. This was double checked to ensure good positioning and this was so. On the lateral view, we could see this was not in the joint. AP views and mortise views showed this was not in the joint. One could palpate this as well. The screw was placed slightly proximal to distal in the anteroposterior plane. At the distal tip of it, it was just in the subchondral bone but not in the joint. There was slight to excellent purchase of this posterior lateral fragment. Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin. Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage. Posterior splint was placed on the patient. The patient's leg was placed in neutral position. Significant amount of cast padding were used and large bulky trauma ABD type dressings. The heel was padded and leg was padded with approximately 2 inches of padding. Tourniquet was deflated. The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications. Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied. Positioning of the leg was accomplished by the physician assistant. As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue. The patient is expected to do well overall. He does have an area of comminution shown on the CT scan. However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment. Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area." }

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

{ "text_length": 10962 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE: ,The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition." }

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

{ "text_length": 2264 }

{ "text": "PREOPERATIVE DIAGNOSIS:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. I discussed the procedure as well as risks and complications. She wishes to proceed with surgery. Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE: ,The patient was taken to the operating room on 10/02/2007. She was intubated for anesthesia. TEDS and boots as well as Foley catheter were placed. She was placed in a supine position with her neck in neutral position. Appropriate pads were also used. The area was prepped and draped in usual sterile fashion. Preoperative localization was taken. _____ not changed. Incision was made on the right side in transverse fashion over C5 vertebral body level. This was made with a #10 blade knife and further taken down with pickups and scissors. The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine. Intraoperative x-ray was taken. Longus colli muscles were retracted laterally. Caspar retractors were used. Intraoperative x-ray was taken. I first turned by attention at C5-C6 interspace. This was opened with #15 blade knife. Disc material was taken out using pituitary as well as Kerrison rongeur. Anterior aspects were taken down. End plates were arthrodesed using curettes. This was done under distraction. Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur. Bilateral foraminotomies were done. At this point, I felt that there was a good decompression. The foramen appeared to be opened. Medtronic cage was then encountered and sent few millimeters. This was packed with demineralized bone matrix. The distraction was then taken down. The cage appeared to be strong. This procedure was then repeated at C4-C5. A 42-mm AcuFix plate was then placed between C4 and C6. This was carefully screwed and locked. The instrumentation appeared to be strong. Intraoperative x-ray was taken. Irrigation was used. Hemostasis was achieved. The platysmas was closed with 3-0 Vicryl stitches. The subcutaneous was closed with 4-0 Vicryl stitches. The skin was closed with Steri-strips. The area was clean and dry and dressed with Telfa and Tegaderm. Soft cervical collar was placed for the patient. She was extubated per anesthesia and brought to the recovery in stable condition." }

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

{ "text_length": 2924 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction." }

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

{ "text_length": 4534 }

{ "text": "CHIEF COMPLAINT:, Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:, This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY: ,Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES: ,There are no known allergies.,MEDICATIONS:, Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:, He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD.,REVIEW OF SYSTEMS:, He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.,ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness.,SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable.,GENITALIA: Deferred.,RECTAL: Deferred.,EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION:, A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day." }

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

{ "text_length": 4107 }

{ "text": "HISTORY:, The patient was in the intensive care unit setting; he was intubated and sedated. The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated. He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output. His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia. Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1. Pancreatitis.,2. Poison ivy. The patient has recently been on oral steroids.,3. Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour. The patient was initially on dopamine, which has now been discontinued. The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:, Vitals, emergency room presentation, the blood pressure was 82/45. His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2. The patient has had minimal urine output since admission. HEENT, the patient is intubated at the moment. Neck examination, no overt lymph node enlargement. No jugular venous distention. Lungs examination is benign in terms of crackles. The patient has some harsh breath sounds secondary to being intubated. CVS, S1 and S2 are fairly regular at the moment. There is no pericardial rub. Abdominal examination, obese, but benign. Extremity examination reveals no lower extremity edema. CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2. The patient's BUN and creatinine yesterday were 23 and 2.1 respectively. H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning. The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55. Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1. Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2. He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis. The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight. Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2. Hypotension, which is significant and is related to his sepsis. Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3. Acidosis, which is again secondary to his renal failure. The patient was administered intravenous bicarbonate as mentioned above. Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4. Pancreatitis, which has been managed by his gastroenterologist.,5. Sepsis, the patient is on broad-spectrum antibiotic therapy.,6. Hypercalcemia. The patient has been given calcium chloride. We will need to watch for rebound hypercalcemia.,7. Hypoalbuminemia.,8. Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration." }

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

{ "text_length": 4065 }

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

{ "text_length": 3973 }

{ "text": "IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , \"I'm here because I'm different.\" The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance. According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile. The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police. On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder. The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup. Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed. The patient resides independently. The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION: ,Attitude: Suspicious, but cooperative.,Appearance: Shows appropriate hygiene and grooming.,Psychomotor Behavior: Within normal limits. No agitation or retardation. No EPS or TDS noted.,Affect: Labile.,Mood: Euphoric.,Speech: Pressured.,Thoughts: Disorganized.,Thought Content: Remarkable for grandiose delusions as noted. The patient denies auditory hallucinations.,Psychosis: Grandiose delusions as noted above.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is oriented x 3.,Judgment: Poor shown by noncompliance to the outpatient treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I: BAD, manic with psychosis.,AXIS II: None.,AXIS III: None known.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely. The patient will be evaluated for more structural outpatient followup following stabilization." }

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

{ "text_length": 2752 }

{ "text": "PREOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,POSTOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,PROCEDURES PERFORMED,1. Sentinel lymph node biopsy.,2. Ultrasound-guided lumpectomy with intraoperative ultrasound.,ANESTHESIA,General LMA anesthesia.,ESTIMATED BLOOD LOSS,Minimum.,IV FLUIDS,Per anesthesia record.,COMPLICATIONS,None.,FINDINGS,Clip well localized within the specimen.,INDICATION,This is a 65-year-old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility, which showed atypical ductal hyperplasia with central necrosis. On reviewing this pathology, it is mostly likely DCIS. The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed. The patient desired MammoSite Radiation Therapy; therefore, the sentinel lymph node biopsy was incorporated into the procedure.,PROCEDURE IN DETAIL,The patient was taken to the operating room, placed in supine position, and general LMA anesthesia was administered. She was prepped and draped in the usual sterile fashion. Prior to the procedure, she underwent nuclear medicine injection with technetium-99 and methylene blue. Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery. Two sentinel lymph nodes were identified, one was blue and hot and the other was just hot. These were sent to Pathology for touch prep. Adequate hemostasis was obtained. The wound was packed and attention was turned to the left breast. Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap. An elliptical incision was made roughly at approximately the 3 o'clock position secondary to subcutaneous tissues with electric Bovie cautery. The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia, which was incorporated within the specimen. The specimen was completely removed and marked **** double deep, and a mini C-arm was used to confirm this. The marker was well localized within the center of the specimen. The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2-0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter. The wound was then closed with a deep layer of interrupted 3-0 Vicryl followed by 3-0 Vicryl subcuticular stitch and 4-0 running Monocryl. The axillary wound was closed with interrupted 3-0 Vicryl and a running 4-0 Monocryl. Steri-Strips were applied. The patient was awakened and extubated in the OR and taken to PACU in stable condition. All counts were reported as correct. I was present for the entire procedure." }

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

{ "text_length": 2795 }