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{ "text": "TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:, This is a 49-year-old gentleman was referred by Dr. A. The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia. He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably. Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty. A J-wire was guided into place under fluoroscopic control. A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene. The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away. Fluoroscopy showed good catheter disposition in the superior vena cava. The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline. The pocket was irrigated using antibiotic saline and closed with absorbable suture. The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy. There were no complications." }

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

{ "text_length": 1621 }

{ "text": "TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma. The patient is having surgery for resection. There was significant cerebellar peduncle compression. The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex. The case took 12 hours. This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:, The patient was brought to the operating room. General anesthesia was induced in the usual fashion. After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area. A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion. The incision was made and cautery was used to expose the suboccipital bone. Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus. The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum. The dura leaves were held back with the 4-0 Nurolon. The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated. Laterally, the arachnoid was very thick. This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified. The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa. Initially two retractors were used, one on the tentorium and one inferiorly. The arachnoid was taken down off the tumor. There were multiple blood vessels on the surface, which were bipolared. The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion. This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized. The redundant capsule was bipolared and cut out to get further access to the center of the tumor. Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex. It was very difficult to identify the 7th nerve complex. The brainstem was identified above the complex. Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain. Attention was then taken to try identify the 7th nerve complex. There were multitude of veins including the lateral pontine vein, which were coming right into this area. The lateral pontine vein was maintained. Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem. A number 1 and number 2 microinstruments were then used to began to develop the plane. This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed. A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve. Cavitron was used to debulk the lesion and then further dissection was carried out. The nerve stimulated beautifully at the brainstem level throughout this. The tumor continued to be mobilized off the lateral pontine vein until it was completely off. The Cavitron was used to debulk the lesion out back laterally towards the area of the porus. The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus. At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus. There was minimal bulk remaining intracranially. All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem. Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor. There was no tumor remaining at this point. I placed some Norian in the porus to seal any air cells, although there were no palpated. An intradural space was then irrigated thoroughly. There was no bleeding. The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time. The dura was then closed with 4-0 Nurolons in interrupted fashion. A muscle plug was used over one area. Duragen was laid and strips over the suture line followed by Hemaseel. Gelfoam was set over this and then a titanium cranioplasty was carried out. The wound was then irrigated thoroughly. O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition." }

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

{ "text_length": 5527 }

{ "text": "INDICATION:, Prostate Cancer.,TECHNIQUE:, 3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections.,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. The uptake in the remainder of the skeleton is within normal limits. The kidneys image normally. There is increased activity in the urinary bladder suggesting possible urinary retention.,CONCLUSION:,1. Focus of abnormal increased tracer activity overlying the right parietal region of the skull. CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2. There is probably some degree of urinary retention.," }

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

{ "text_length": 804 }

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

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

{ "text_length": 3510 }

{ "text": "DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age." }

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

{ "text_length": 970 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,PROCEDURE PERFORMED:,1. Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2. McCall's culdoplasty.,3. Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS: ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia. On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated. The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY: ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities. On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis. There was also evidence of fibroid change in the right fundal aspect of the uterus. There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes. There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in the normal sterile fashion. A Foley catheter was initially placed and was noted to be draining clear to yellow urine. A weighted speculum was placed in the patient's vagina. The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus sounded to 7 cm and the cervix was then progressively dilated. A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator. At this time, after the gloves were changed, attention was then turned to the patient's abdomen. A small approximately 1 cm infraumbilical incision was made with the scalpel. A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures. A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope. On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions. There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance. At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope. A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope. Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site. The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper. The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time. Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper. An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament. At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic. In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted. At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers. The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated. The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure. At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic. The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure. The weighted speculum was placed into the patient's vagina. At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb. The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure. The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps. The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position. The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly. Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly. At this time, two curved Heaney clamps were placed across the uterine artery on the right. This was then transected and suture ligated with #0 Vicryl suture. The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture. Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture. This second clamp was then advanced to capture the vasculature and the cardinal ligament complex. This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff. Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology. At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure. Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position. Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly. The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum. Two additional sutures medially were placed and these were tagged and not tied in place. A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized. This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches. At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg. The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic. The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time. The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time. The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen. The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia. The Steri-Strips were placed. The patient tolerated the procedure well and taken to recovery in stable condition. Sponge, lap, and needle counts were correct x2. The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes. The patient will have her Foley catheter maintained for approximately 7 to 10 days." }

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

{ "text_length": 9827 }

{ "text": "PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition." }

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

{ "text_length": 1505 }

{ "text": "PROCEDURE: ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze. Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions. Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus. Saccadic movements did not reveal any evidence of dysmetria or overshoot. Sinusoidal tracking was performed well for the patient's age. Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands. Therefore adequate OKNs were not achieved. The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again. The patient complained of severe dizziness in this position. There was no clear-cut decremental response with repetition. In the head hanging left position, no significant nystagmus was identified. Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position. No other significant nystagmus was noted. There was no evidence of clear-cut caloric stimulation abnormality. This study would be most consistent with a right vestibular dysfunction." }

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

{ "text_length": 1948 }

{ "text": "HISTORY:, The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improvement. She has loose bowel movements. She complains of no bladder control. She has pain in her hips. The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1. Type II diabetes mellitus.,2. Generalized fatigue and weakness.,3. Hypertension.,4. Peripheral neuropathy with atypical symptoms.,5. Hypothyroidism.,6. Depression.,7. Long-term use of high-risk medications.,8. Postmenopausal age-related symptoms.,9. Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.,PAST SURGICAL HISTORY:, As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy.,SOCIAL HISTORY: ,She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL: Certainly at the present time on general exam no fever, sweats or chills and no significant weight change. She is 189 pounds currently and she was 188 pounds in January.,HEENT: HEENT, there is no marked decrease in visual or auditory function. ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY: Chest, there is no history of palpitations, PND or orthopnea. The chest pains are nonspecific, tenderness to palpation has been reported. There is no wheezing or cough reported.,CARDIOVASCULAR: No PND or orthopnea. Thromboembolic disease history.,GASTROINTESTINAL: Intermittent symptoms of stomach pain, they are nonspecific. No nausea or vomiting noted. Diarrhea is episodic and more related to nerves.,GENITOURINARY: She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL: Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL: No marked paralysis, paresis or paresthesias.,SKIN: No rashes, itching or changes in the nails.,BREASTS: No report of any lumps or masses.,HEMATOLOGY AND IMMUNE: No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT: 189 pounds. BP: 140/80. PULSE: 76. RESPIRATIONS: 20. GENERAL APPEARANCE: Well developed, well nourished. No acute distress.,HEENT: Head is normocephalic. Ears, nose, and throat, normal conjunctivae. Pupils are reactive. Ear canals are patent. TMs are normal. Nose, nares patent. Septum midline. Oral mucosa is normal in appearance. No tonsillar lesions, exudate or asymmetry. Neck, adequate range of motion. No thyromegaly or adenopathy.,CHEST: Symmetric with clear lungs clear to auscultation and percussion.,HEART: Rate and rhythm is regular. S1 and S2 audible. No appreciable murmur or gallop.,ABDOMEN: Soft. No masses, guarding, rigidity, tenderness or flank pain.,GU: No examined.,EXTREMITIES: No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS: Intact. No lesions or rashes.,NEUROLOGIC: Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:," }

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

{ "text_length": 3652 }

{ "text": "SUBJECTIVE: , I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had significant gross hematuria this month. He also fell about a week ago and is complaining of buttock pain and leg pain. We did get x-rays of hips, knees, and ankles. Clearly, he has significant degenerative disease in all these areas. No fractures noted however. He felt that the pain is pretty severe and particularly worse in the morning. His sinuses are bothering him. He wonders about getting some nasal saline spray. We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals: As in chart. The patient is alert, pleasant, and cooperative. He is not in any apparent distress. He is comfortable in a seated position. I did not examine him further today.,ASSESSMENT AND PLAN:,1. Hematuria. Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH. We will also obtain a repeat UA as he did describe to me some dysuria. However, I do not think this would account for the gross hematuria. He will be started on an aspirin 81 mg p.o. daily.,2. For the pain we will try him on Lortab. He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3. We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4. For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use." }

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

{ "text_length": 1807 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis." }

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

{ "text_length": 5829 }

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

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

{ "text_length": 4668 }

{ "text": "PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition." }

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

{ "text_length": 1105 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies any abdominal pain. Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine. The patient is not sure of his immunizations. The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid. None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL: He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular.,ABDOMEN: Soft. He has pain over the mid to lower spine.,SKIN: Color is normal.,EXTREMITIES: He moves all extremities well.,NEUROLOGIC: Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION: ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis." }

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

{ "text_length": 2944 }

{ "text": "TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall. He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:, General.,SPECIMEN:, None.,IMPLANTS:,1. Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2. Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife. All of their questions were answered. Informed consent was signed. The patient was brought into the operating room. A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye. After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery. A wire lid speculum was used to separate the eyelids of the left eye. A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon. The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried. A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors. Hemostasis was achieved with bipolar cautery. A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant. A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture. The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion. Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule. The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter. The vitreous was trimmed to the vitreous base. A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course. The exit wound was explored. No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps. The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression. No retinal breaks or defects were noted in the periphery. The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees. Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve. The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion. The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures. A 12% concentration of C3F8 gas was flushed through the eye. The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture. All of the sclerotomies were noted to be airtight. The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried. Subconjunctival injections of Ancef and Decadron were delivered inferotemporally. The lid speculum was removed. Pred-G ointment and atropine solution were applied to the ocular surface. The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well. There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure." }

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

{ "text_length": 5576 }

{ "text": "CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:," }

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

{ "text_length": 64 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Nasopharyngeal mass.,2. Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1. Nasopharyngeal tube mass.,2. Right upper lid skin lesion.,PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Excision of nasopharyngeal mass via endoscopic technique.,3. Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan. The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. It appears to be growing in size and is irregularly bordered. After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position. After this, the patient was turned to 90 degrees by the Department of Anesthesia. The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade. After this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors. After this, the ________ was then hemostatically controlled with monopolar cauterization. The patient's skin was then reapproximated with a running #6-0 Prolene suture. A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment. Attention then was drawn to the nasopharynx. The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. The patient had a severely deviated nasal septum more so to the right than the left. There appeared to be a spur on the left inferior aspect and also on the right posterior aspect. The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. After this, the lesion was then removed on the right side with the XPS blade. The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. This area was taken down with the XPS blade. Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter. After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. After this, the patient was then hemostatically controlled with suctioned Bovie cauterization. A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment. The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia. The patient was extubated in the operating room and was transferred to the recovery room in stable condition. The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30." }

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

{ "text_length": 4218 }

{ "text": "PROBLEM:, Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty. At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity. However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels. Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise. Her prothrombin time is now 83.3 seconds with an INR of 6.52. Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever. The patient has usual childhood illnesses.,ALLERGIES: ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer. She had a brother who died from mesothelioma. He did have a positive asbestos exposure working in the shipyards. The patient's father died from motor vehicle accident. She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X. In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1. Fosamax.,2. TriCor.,3. Gabapentin.,4. Hydrochlorothiazide.,5. Labetalol.,6. Benicar.,7. Crestor.,8. Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time. She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL: The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT: Pupils were equal, round, and reactive to light and accommodation. Extraocular muscles are grossly intact. Oropharynx benign.,NECK: Supple. Full range of motion without bruits or thyromegaly.,LUNGS: Clear to auscultation and percussion.,BACK: Without spine or CVA tenderness.,HEART: Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN: Soft and nontender. Positive bowel sounds without mass or visceromegaly.,LYMPHATIC: No appreciable adenopathy.,EXTREMITIES: The patient has some postoperative fullness involving her left knee. She has a dressing over the left knee.,SKIN: Without lesions.,NEURO: Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time. Literature suggested oral vitamin K is actually more efficacious than parenteral. However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion. Repeat prothrombin time and INR in a.m. Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively." }

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

{ "text_length": 3962 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions." }

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

{ "text_length": 1481 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion. The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X. At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment. Incidentally, the ulcer is noninfective and practically healed at this date. The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection. A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operating field and a sterile stockinet was reflected. The Betadine was cleansed with saline-soaked gauze and dried. Anesthesia was tested with a one tooth pickup and found to be adequate. A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint. A #15 blade was used to deepen the incision to the subcutaneous layer. Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally. Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia. A linear capsular incision was made with a #15 blade down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade. Metatarsal head was delivered into the wound. There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer. The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe. A sagittal saw was used to resect the hypertrophic lateral eminence. The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity. Next, a reciprocating rasp was used to smoothen all bony surfaces. The bone stock had an excellent healthy appearance and did not appear to be infected. Copious amount of sterile gentamicin impregnated saline were used to flush the wound. The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique. The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique. A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits. The patient tolerated the above anesthesia and procedure without complications. He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. He was given a postop shoe and will be full weightbearing. He has prescription already at home for hydrocodone and does not need to refill. He is to follow up with Dr. X and was given emergency contact numbers. He was discharged in stable condition." }

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

{ "text_length": 4122 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Torn rotator cuff, right shoulder.,2. Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with subacromial decompression.,2. Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity. There is moderate amount of synovitis noted throughout the glenohumeral joint. There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital. She was placed supine on the operating table. General anesthesia was applied by the Anesthesiology Department. She was placed in the modified beachchair position. Her upper extremity was sterilely prepped and draped in usual fashion. A stab incision was made in the posterior aspect of the glenohumeral joint. A camera was placed in the joint and was insufflated with saline solution. Intraoperative pictures were obtained and the above findings were noted. A second port site was initiated anteriorly. Through this a probe was placed and the intraarticular structures were palpated and found to be intact. A tear of the inner surface of the rotator cuff was identified. The camera was then taken to the subacromial space. A straight lateral portal was also used and a shaver was placed into the subacromial space. Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed. The edges of the rotator cuff were then debrided. The camera was then removed and the shoulder was suction and dried. A lateral incision was made over the anterolateral border of the acromion. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur. A trough was then made in the greater tuberosity using the rongeur. Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff. The ends of the suture were tied down from the fixating the rotator cuff within the trough. The rotator cuff was then further oversewed using the Panalok suture. The wound was then copiously irrigated and it was then suction dried. The deltoid muscle was reapproximated using #1 Vicryl. A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control. The subcutaneous tissues were reapproximated with #2-0 Vicryl. The skin was closed with #4-0 PDS running subcuticular stitch. Sterile dressing was applied to the upper extremity. She was then placed in a shoulder immobilizer. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient was guarded. She will begin pendulum exercises postoperative day #3. She will follow back in the office in 10 to 14 days for reevaluation. Physical therapy initiated approximately six weeks postoperatively." }

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

{ "text_length": 3868 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has \"terrible quality sleep.\",MEDICATIONS: , Current medications are as previously noted. Changes include reduction in prednisone from 9 to 6 mg by mouth every morning. She continues to take Ativan 1 mg every six hours as needed. She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs: Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest. Chest is clear. Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. She used it for greater than 4 hours per night on 67% of night surveyed. Her estimated apnea/hypopnea index was 3 per hour. Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour. Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%. During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1. Obesity hypoventilation syndrome. The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2. Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute. The breathing pattern is that of cluster or Biot's breathing throughout sleep. The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3. Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4. Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. These will include, (1). Decrease in evening doses of MS Contin, (2). Modest weight loss of approximately 10 to 20 pounds, and (3). Instituting Automated Servo Ventilation via nasal mask. With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed. I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time. She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing." }

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

{ "text_length": 5058 }

{ "text": "HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids only. He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips. Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow. Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid. Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow. The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule. The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids. The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food. The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling. Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation. The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid. No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1. The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2. The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3. The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4. The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient. I look forward to working with him in the outpatient setting to improve his swallowing function and safety. Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety." }

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

{ "text_length": 3846 }

{ "text": "CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.," }

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

{ "text_length": 2009 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1. Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2. Bilateral C6 nerve root decompression.,3. Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4. Bilateral C5 nerve root decompression.,5. Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6. Bilateral C4 nerve root decompression.,7. Harvesting of autologous bone from the vertebral bodies.,8. Grafting of allograft bone for creation of arthrodesis.,9. Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12. Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6. There was a herniated disk with cord compression and radiculopathy at C4-C5. C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels. Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives. He clearly understands and has no further questions and requests that I proceed.,PROCEDURE: ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease. Dissection was carried down through the platysma musculature and the anterior spine was exposed. The medial borders of the longus colli muscle were dissected free from their attachments to the spine. Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained. A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space. The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies. The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament. The ligament was incised and the underlying dura was exposed. I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen. There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact. However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right. The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5. I worked down through bony osteophytes and identified the posterior longitudinal ligament. The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces. The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen. The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it. Again the microscope was angled to the left side where similar decompression was achieved. Central decompression was achieved here where there was a moderate amount of spinal cord compression. This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space. Here there were large osteophytes projecting posteriorly against the cord. I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord. This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord. I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right. The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis. A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration. Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis. Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4. Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge. I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks. The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described. An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation. Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate. The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush. The holes were drilled and the screws were placed. Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6. All eight screws had good purchase. The locking screws were tightly applied. An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure. The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained. A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct. There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue." }

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

{ "text_length": 8170 }

{ "text": "CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain. The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath. The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates. Aggravated by breathing, coughing, and palpation over the area. The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted. Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5. The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together. The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:, Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure. The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:, History of alcohol use in the past.,He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable.,GENERAL: Alert and oriented x3, no apparent distress.,HEENT: Extraocular muscles are intact.,CVS: S1, S2 heard.,CHEST: Clear to auscultation bilaterally.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema or clubbing.,NEURO: Grossly intact. Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. Continue to follow the patient clinically at this time. The patient has been admitted to ICU and will be changed to DOU.,2. Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes. The patient likely has opioid dependence and requesting more and more pain medications. He is also bargaining for pain medications with me. The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days. The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred. We will try to verify his pain medications from his primary doctor and his pharmacy. The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past." }

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

{ "text_length": 3246 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:, None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time." }

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

{ "text_length": 2901 }

{ "text": "CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and \"Right upper lobe lung\". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:, Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type,COMMENT:, Right upper lobe, lobectomy.,Tumor type: Bronchioloalveolar carcinoma, mucinous type.,Histologic grade: Well differentiated.,Tumor size (greatest diameter): 3.6 cm.,Blood/lymphatic vessel invasion: Absent.,Perineural invasion: Absent.,Bronchial margin: Negative.,Vascular margin: Negative.,Inked surgical margin: Negative.,Visceral pleura: Not involved.,In situ carcinoma: Absent.,Non-neoplastic lung: Emphysema.,Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.,P53 immunohistochemical stain is negative in the tumor." }

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

{ "text_length": 1459 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1. Diagnostic laparotomy.,2. Exploratory laparotomy.,3. Meckel's diverticulectomy.,4. Open incidental appendectomy.,5. Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:, 1600 mL.,DRAIN:, JP x1 right lower quadrant and anterior to the rectum.,TUBES:, Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity. The patient has had anorexia with decrease in appetite. His physical examination revealed the patient to be febrile with the temperature of 102.4. He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen. The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy. He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum. There was large amounts of purulent drainage. The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema. It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy. Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected. Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed. The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters. The patient was closed and did develop some hypoxemia after closure. He remained ventilated and was placed on a large amount of ________. His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:, The patient was brought to the operative suite and placed in the supine position. He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously. The patient was intubated by the Anesthesia Department. After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution. Utilizing a #10 blade scalpel, an infraumbilical incision was created. The Veress needle was inserted into the abdomen. The abdomen was insufflated to approximately 15 mmHg. A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted. A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix. Decision was then made to convert to exploratory laparotomy given the signs of acute perforation. The instruments were then removed. The abdomen was then deflated. Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery. The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy. Incision was carried down to the midline within the linea alba. Once the abdomen was opened, there was noted to be gross purulent drainage. The ileum was explored and there was noted to be a perforated Meckel's diverticulum. Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum. Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures. The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected. There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage. Next, decision was decided to go ahead and perform an appendectomy. Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors. The appendiceal artery was identified and was clamped between two hemostats and transected as well. Once the appendix was completely freed of the surrounding inflammation and adhesion. A plain gut was placed at the base of the appendix and tied down. The appendix was milked distally with a straight stat and clamped approximately halfway. A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel. The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture. Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed. The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall. It was sewn in place with a #3-0 nylon suture. The abdomen was then irrigated with copious amounts of warmed normal saline. The remainder of the abdomen was unremarkable for pathology. The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture. Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples. The previous laparoscopic sites were also closed with staples. Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs. JPs replaced with bulb suction. NG tube and Foley catheter were left in place. The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course. To remain on IV antibiotics and we will manage ventilatory-dependency of the patient." }

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

{ "text_length": 6942 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:, Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition." }

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

{ "text_length": 2355 }

{ "text": "Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:, Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:, The patient denies any past surgical history.,MEDICATIONS:, The patient takes Cardizem CD 240-mg. The patient also takes eye drops.,ALLERGIES:, The patient denies any allergies.,SOCIAL HISTORY:, The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially.,FAMILY HISTORY:, Significant for hypertension and strokes.,REVIEW OF SYSTEMS:, The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:, This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema.,IMPRESSION:, This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.,1. Rule out colon cancer.,2. Rule out colon polyps. ,3. Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:, Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD" }

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

{ "text_length": 2576 }

{ "text": "CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:, A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly., ,PAST MEDICAL HISTORY:, Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.,General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull." }

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

{ "text_length": 1271 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,4. Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1. Bilateral myringotomies.,2. Placement of ventilating tubes.,3. Nasal endoscopy.,4. Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin. Ears were inspected then with the operating microscope. The anterior inferior quadrant myringotomy incisions were performed. Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated. The middle ear mucosa looked remarkably clean. Armstrong tubes were inserted. Ciprodex drops were instilled. Ciprodex will be planned for two postoperative days as well. Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products. The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken. Additional adenoid tissue was shaved backwards with the RADenoid shaver. Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished. The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken. That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx. Electrocautery again used to establish hemostasis. Bleeding was trivial. Extensive irrigation accomplished. No additional bleeding was evident. The patient was awakened, extubated, taken to the recovery room in a stable condition. Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain. Office recheck would be anticipated if stable and doing well in approximately two weeks. Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic." }

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

{ "text_length": 2663 }

{ "text": "PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition." }

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

{ "text_length": 1505 }

{ "text": "PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern. Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area. All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION: ,Postprocedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week." }

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

{ "text_length": 3175 }

{ "text": "HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer." }

[ { "label": " Physical Medicine - Rehab", "score": 1 } ]

{ "text_length": 2457 }

{ "text": "PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: ,INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition." }

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

{ "text_length": 1648 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, 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. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the \"Scotty Dog,\" After obtaining the \"Scotty Dog\" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the \"Scotty Dog\" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis." }

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

{ "text_length": 3090 }

{ "text": "PROCEDURE:, Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:, See nurse's notes.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. Xylocaine 1.5% for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made. A 20-gauge, 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection, it was noted to be along the anterior vertebral body, at the junction of the upper two thirds, lower one third of the body. After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body. After negative aspiration 18 cc of 0.25% Marcaine was injected. Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third, lower two third of L3. At this point, after confirmation of the linear spread of dye along the anterior portion of the body, negative aspiration was performed and 18 cc of 0.25% Marcaine was injected. Neosporin and band-aids were applied over the sites. The patient was taken to the outpatient recovery room in stable condition." }

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

{ "text_length": 1359 }

{ "text": "She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications. She states that the methadone did not work for her. She was \"immune\" to oxycodone. She had been on tramadol before and was placed back on that. There was some question that this may have been causing some dizziness. She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon. He had a box of her pain medications. It is unclear whether she took a bunch of these or precisely what happened. I was contacted that she was less responsive. She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain. The nurse found her and was unable to arouse her at this point. There was a concern that she had taken some medications from home. She was given Narcan and appeared to come around some. Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m. Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity. With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted. A chest x-ray was obtained at this time. An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU. We will continue the IV Zosyn. Respiratory protocol with respiratory management. Continue alprazolam p.r.n., but avoid if she appears sedated. We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being. I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. At this juncture, she does not appear to need an intubation. Pending chest x-ray, she may require additional IV furosemide." }

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

{ "text_length": 2387 }

{ "text": "DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance." }

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

{ "text_length": 6127 }

{ "text": "CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS: ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:, Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL: Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST: Shows bilateral air entry present, clear to auscultate.,HEART: S1 and S2 regular.,ABDOMEN: Soft, nondistended, and nontender.,EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2. Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3. Hypertension, now hypotension.,4. Incontinence of the bladder.,5. Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control." }

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

{ "text_length": 4737 }

{ "text": "CHIEF COMPLAINT: ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain, does not have fever and has no other problems or complaints. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. The patient states he feels like his usual self and has no other problems or concerns. The patient denies any fever or chills. No nausea or vomiting. No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well. HEENT: Eyes are normal with clear sclerae and cornea. NECK: Supple, full range of motion. CARDIOVASCULAR: Heart has regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. No dependent edema. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. Normal benign abdominal exam. MUSCULOSKELETAL: The patient has nontender back and flank. No abnormalities noted to the back other than the bilateral nephrostomy tubes. The nephrostomy tube left has no abnormalities, no sign of infection. No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it. There is no obvious active leak from the ostomy site. No sign of infection. No erythema, swelling or tenderness. The collection bag is full of clear urine. The patient has no abnormalities on his legs. SKIN: No rashes or lesions. No sign of infection. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal ambulation, normal speech. PSYCHIATRIC: Alert and oriented x4. Normal mood and affect. HEMATOLOGIC AND LYMPHATIC: No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:, Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes. There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes. Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X. Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow. This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1. WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2. PROSTATE CANCER, METASTATIC.,3. URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X. The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns." }

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

{ "text_length": 4398 }

{ "text": "PROCEDURES PERFORMED:, Colonoscopy.,INDICATIONS:, Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics discussed. Preprocedure physical exam performed. Stable vital signs. Lungs clear. Cardiac exam showed regular rhythm. Abdomen soft. Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed. She currently has a flare and is not responding, therefore, likely may require steroid taper. At the same token, her symptoms are mild. She has rectal bleeding, essentially only some rusty stools. There is not significant diarrhea, just some lower stools. No significant pain. Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed. Past history reviewed. Specifics of workup, need for followup, and similar discussed. All questions answered.,A normal digital rectal examination was performed. The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice. All mucosal aspects thoroughly inspected, including a retroflexed examination. Withdrawal time was greater than six minutes. Unfortunately, the terminal ileum could not be intubated despite multiple attempts.,Findings were those of a normal cecum, right colon, transverse colon, descending colon. A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1. Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3. There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4. There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion. Retroflexed showed hemorrhoidal disease. Scope was then withdrawn, patient left in good condition. ,IMPRESSION:, Active flare of Inflammatory Bowel Disease, question of Crohn disease.,PLAN: , I will have the patient follow up with me, will follow up on histology, follow up on the polyps. She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job. If not, she may be started on immune suppressive medication, such as azathioprine, or similar. All of this has been reviewed with the patient. All questions answered." }

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

{ "text_length": 3102 }

{ "text": "EXAM: , Digital screening mammogram.,HISTORY:, 51-year-old female presents for screening mammography. Patient denies personal history of breast cancer. Breast cancer was reported in her maternal aunt.,TECHNIQUE:, Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS: ,The breasts demonstrate a mixture of adipose and fibroglandular elements. Composition appears similar. Multiple tiny punctate benign-appearing calcifications are visualized bilaterally. No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen. Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings. Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized." }

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

{ "text_length": 1289 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1. Pelvic mass.,2. Suspected right ovarian cyst.,PROCEDURES,1. Exploratory laparotomy.,2. Extensive lysis of adhesions.,3. Right salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS: ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them. The large and small bowels were completely enveloping a large right ovarian cystic mass. Normal anatomy was difficult to see due to adhesions. Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid. Cyst wall, tube, and ovary were stripped away from the bowel. Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube. There was excellent postoperative hemostasis.,PROCEDURE: ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty. She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion. A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision. Incision was carried down carefully until the peritoneal cavity was reached. Care was taken upon entry of the peritoneum to avoid injury of underlying structures. At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery. The omentum was carefully stripped away from the patient's right side developing a window. This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum. A large mass of bowel was noted to be adherent to itself causing a quite tortuous course. Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis. Excellent hemostasis was noted. The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst. Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst. Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured. Large amount of turbid fluid was noted and was evacuated. The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel. Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter. This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl. A suture ligature of #0 Vicryl was used to obtain hemostasis. Excellent hemostasis was noted at this pedicle. The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum. Care was taken at the side of the remnant of the uterine vessels. However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted. Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube. Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal. It was then left in situ. Hemostasis was achieved in the pelvis with the use of electrocautery. The abdomen and pelvis were copiously irrigated with warm saline solution. The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle. The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen. The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly. Excellent closure of the incision was noted. The subcutaneous tissues were then copiously irrigated. Hemostasis was achieved with the use of cautery. Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture. The skin was closed with staples.,Incision was sterilely clean and dressed. The patient was awakened from general anesthesia and taken to the recovery room in stable condition. All counts were noted correct times three." }

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

{ "text_length": 5464 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room. The abdominal contents were within normal limits. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution. A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area. Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges. Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery. Mild adhesions were lysed. The omentum was freed. The small and large intestine were run with no evidence of abnormalities. The liver and gallbladder were within normal limits. No abnormalities were noted. At this point, the Bookwalter retractor was placed. NG tube was placed in the stomach and placed on suction. The intestines were gently packed intraabdominally and laterally. The rest of the peritoneum was then opened. The aorta was cleared, both proximally and distally. The left iliac was completely occluded. The right iliac was to be cleansed. At this point, 5000 units of aqueous heparin was administered to allow take effect. The aorta was then clamped below the renal arteries and opened in a longitudinal fashion. A single lumbar was ligated with #3-0 Prolene. The inferior mesenteric artery was occluded intraluminally and required no suture closure. Care was taken to preserve collaterals. The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion. Last stitch was tied. Hemostasis was excellent. The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis. At this point, strong pulses were present within the graft. The limbs were vented and irrigated. Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin. The grafts were then brought through these, care being taken to avoid twisting of the graft. At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed. Hemostasis was excellent. The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors. The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion. Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied. Flow was initially restored proximally then distally with good results. Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally. The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis. The last stitch was tied. Strong pulses were present within the artery and graft itself. At this point, 25 mg of protamine was administered. The wounds were irrigated with antibiotic solution. The groins were repacked. Attention was then returned to the abdomen. The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present. The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft. The intraabdominal contents were then allowed to resume their normal position. There was no evidence of ischemia to the large or small bowel. At this point, the omentum and stomach were repositioned. The abdominal wall was closed in a running single layer fashion using #1 PDS. The skin was closed with skin staples. The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips. The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well. Sponges and instrument counts were correct. Estimated blood loss 900 cc." }

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

{ "text_length": 4944 }

{ "text": "PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition." }

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

{ "text_length": 7339 }

{ "text": "PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1. Renal pelvis.,2. Kidney stones.,INDICATIONS: ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries. Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL: ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out. After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated. Great care was taken to pad all pressure points and a right arm hanger was used. The patient was flexed slightly, and a kidney rest was used. Sequential compression devices were also placed. Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine. Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test. A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas. Next, a 12-mm camera port was placed near the umbilicus. The camera was inserted, and no bowel injury was seen. Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed. The robot was docked and the instruments passed through respective checks. Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially. Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum. At this point, the right kidney was in clear view, and the fascia was entered. Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection. It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole. These arteries were dissected carefully and vessel loops were applied. Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out. The pyelotomy was extended so that the renal collecting system could be directly inspected. Sequentially, each major calyx was inspected under direct vision and irrigated. A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient. At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis. The proximal ureter was spatulated using cold scissors. Next, redundant renal pelvis was excised using cold scissors and sent for permanent section. We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion. 3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis. Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures. Before final stitches were placed, a 6x28 ureteral stent was placed anterograde. This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter. This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision. Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures. Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis. Good pulsation was verified by direct vision proximal and distal to these pexy sutures. Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum. Hemostasis appeared excellent at this point. There was no obvious urine extravasation. At this time, the procedure was terminated. The robot was undocked. Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion. Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this. Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision. The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery." }

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

{ "text_length": 5304 }

{ "text": "PREOPERATIVE DIAGNOSES:, Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS: ,Uterine fragments.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty. The patient was placed in dorsal lithotomy position. Examination under anesthesia revealed an anteverted uterus and no adnexal masses. The patient was prepped and draped in normal sterile fashion. A Foley catheter was placed in the patient's bladder. The patient's cervix was visualized with speculum. A single-tooth tenaculum was placed on the anterior lip of the cervix. A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated. The tenaculum and speculum were then removed from the vagina. Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel. Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg. Veress needle was removed and then 5-mm trocar was placed through the umbilical incision. Laparoscope was placed through this incision and the patient's abdominal contents were visualized. A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope. A trocar incision was made in the right lower quadrant. A 10-mm trocar was placed through this incision under direct visualization with the laparoscope. A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope. The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe. The Gyrus cautery was used to cauterize and cut the right and left round ligaments. The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment. The right uteroovarian ligament was cauterized and cut using the Gyrus. The uterine vessels were then bluntly dissected. The Gyrus was then used to cauterize the right uterine vessels. Gyrus was then used on the left side to cauterize and cut the left round ligament. The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut. Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected. The left uterine vessels were then cauterized and cut using the Gyrus. At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching. At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels. The HUMI manipulator was removed prior to amputation of the uterine body. After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator. The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision. Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated. The Harmonic scalpel was used to cauterize the remaining endocervical canal. The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles. The Harmonic scalpel was then used to incise the right ovarian simple cyst. The right ovarian cyst was then drained yielding straw-colored fluid. The site of right ovarian cystotomy was noted to be hemostatic. The pelvis was again inspected and noted to be hemostatic. The ureters were identified on both sides and noted to be intact throughout the visualized course. All instruments were then removed from the patient's abdomen and the abdomen was deflated. The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion. The cervix was then visualized with the speculum. Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks. All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2. The patient was awoken from anesthesia and then transferred to the recovery room in stable condition." }

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

{ "text_length": 4929 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1. Atrophic dry cracked nasal mucosa.,2. Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess. The patient was taken to the operating room for incision and drainage. Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis. Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery. The patient does report of having endotracheal tube intubation during anesthesia. The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:, After the procedure was described, the patient was placed in the seated position. The fiberoptic nasal laryngoscope was then inserted into the patient's left naris. The nasal mucosal membranes were dry and atrophic throughout. There was no evidence of any mass lesions. The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity. There was no evidence of mass, ulceration, lesion, or obstruction. The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes. There was no evidence of any local mass lesion, nodule, or ulcerations. There was no evidence of any erythema. Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric. The airway was stable and patent throughout the entire examination. The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx. The eustachian tube was completely visualized and was patent without obstruction. The scope was then further removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris. At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma. If this becomes possible in the future, this may provide her some relief of her chronic dysphonia. The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems." }

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

{ "text_length": 3327 }

{ "text": "Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam." }

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

{ "text_length": 4357 }

{ "text": "TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding. The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping. Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles. The patient also had a right subtemporal depression, which was full preoperatively. The entire old apparatus was dissected out. We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted. They were both inspected. No definite debris were seen. After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter. On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location. The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture. The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir. All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips. The patient tolerated the procedure well without complications. CSF was not sent off." }

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

{ "text_length": 3008 }

{ "text": "GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:, The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL: ,The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions. Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:, Mental status, judgment and affect are grossly intact and normal for age." }

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

{ "text_length": 1160 }

{ "text": "REASON FOR VISIT:, Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3. Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. Abdomen: Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:, The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. Questions regarding hospital course and recovery were addressed. We will continue on the Medifast diet until the time of surgery and cleared for surgery." }

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

{ "text_length": 1034 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE: , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications." }

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

{ "text_length": 2553 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a \"floppy tail\" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition." }

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

{ "text_length": 5525 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2. Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2. Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2. Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3. Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:, General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces. Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner. Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided. The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status. The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed. The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away. Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion. At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type." }

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

{ "text_length": 3982 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:, Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma. He did not return for followup or radiotherapy as instructed, and the tumor has regrown. For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible. The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him. Many risks including CSF leak and blindness were discussed in detail. After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE: ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position. Care was taken to pad all pressure points appropriately. The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space. Clear and colorless CSF issued forth. A catheter was inserted to a distance of 40 cm, and the needle was removed. The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas. Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor. This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed. He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder. Care was taken to pad all pressure points appropriately. The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection. The metallic arm was then connected to the table for the use of the endoscope. The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use. Hemostasis was obtained. The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril. The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium. Needle Bovie electrocautery was used to clear mucosa away from the ostium. The perpendicular plate of the ethmoid had already been separated from the sphenoid. I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this. I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of. The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized. Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma. A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor. I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free. The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right. There appeared to be cavernous sinus invasion on the left. It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter. A large amount of this was removed. There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor. While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus. In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression. Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained. I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction. I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air. Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation. The middle turbinates were then restored to their anatomic position. There was no significant intranasal bleeding, and for this reason, an open nasal packing was required. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition. The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor." }

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

{ "text_length": 6834 }

{ "text": "EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:, There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion." }

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

{ "text_length": 2794 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week." }

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

{ "text_length": 4700 }

{ "text": "HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:, She takes meats, vegetables, and fruits. Eats well. Has may be 1 to 2 cups a day of milk. Her calcium intake could be better. She does not drink that much pop but she likes koolaid. Her stools are normal. Brushes her teeth. Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year. Hearing and vision, no problems. She wears corrective lenses. She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas. She did go to Burton this last year. She also plays clarinet, and will be involved also in cheerleading. She likes to swim in the summer time. Her menarche was January 2004. It occurs every 7 weeks. No particular problems at this time.,OTHER ACTIVITIES: ,TV time about 2 to 3 hours a day. She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:, Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d. 120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:, No known drug allergies.,OBJECTIVE:,Vital Signs: Blood pressure: 98/60. Temperature: 96.6 tympanic. Weight: 107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches. Her body mass index is 18.1, which is 40th percentile. Pulse: 68.,HEENT: Normocephalic. Fundi benign. Pupils are equal and reactive to light and accommodation. Conjunctivae were non-injected. Her pupils were equal, and reactive to light and accommodation. No strabismus. She wears glasses. Her vision was 20/20 in both eyes. TMs are bilaterally clear. Nonerythematous. Hearing in the ears, she was able to pass 40 decibel to 30 decibel. With the right ear, she has some problems, but the left ear she passed. Throat was clear. Nonerythematous. Good dentition.,Neck: Supple. Thyroid normal sized. No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory: Clear. No wheezes and no crackles. No tachypnea and no retractions.,Cardiovascular: Regular rate and rhythm. S1 and S2 normal. No murmur.,Abdomen: Soft. No organomegaly and no masses. No hepatosplenomegaly.,GU: Normal female genitalia. Tanner stage III in breast and pubic hair development and she was given a breast exam. Negative for any masses.,Skin: Without rash.,Extremities: Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological: Romberg negative.,Back: No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:, Sports physical with normal growth and development.,PLAN:, If problems continue, she will need to have her hearing rechecked. Hopefully in the school, there will be a screening mat. She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months. We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996. When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release. We talked about her menarche. Recommended the exam of the breast regularly. Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications. She also has had problems with her ankles in the past. She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office." }

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

{ "text_length": 3554 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:, Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had been marked preoperatively. This area was anesthetized with a mixture of Marcaine and Xylocaine. A transverse incision was made over the hernia and dissection carried down to the entrapped fat. Sharp dissection was carried around the fat down to the fascial edge. The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures. The fascial edges were injected with the local anesthetic mixture. Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl. Steri-Strips and a sterile dressing were applied to complete the closure. The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None." }

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

{ "text_length": 1190 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:, Metopic synostosis with trigonocephaly.,PROCEDURES: ,1. Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2. Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3. Bilateral forehead reconstruction with autologous graft.,4. Advancement of the temporalis muscle bilaterally.,5. Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut. Scalp was clipped. He was prepped with ChloraPrep. Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis. Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly. These were subgaleal flaps. Bipolar and Bovie cautery were used for hemostasis. The craniectomy was outlined with methylene blue. The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture. One was just above the nasion and the other was near the bregma. Also bilateral pterional bur holes were drilled. There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut. I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately. Great care was taken when removing the bone from the midline. Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents. Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally. This was a very thick and vertically oriented orbital roof on each side. Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura. The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet. Bone wax was used for hemostasis. It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed. So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit. This was done with the Midas Rex drill using B5 bit. Also, the marked ridge just above the nasion was burred down with the Midas Rex drill. The osteotomies were also carried down through the zygoma. At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim. This created a shelf for the notched bone graft to lean against basically anteriorly. The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture. This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation. Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good. The advancement was about 1 cm and we were pleased with the results. The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin. The patient tolerated procedure well. No complications. Sponge and needle counts were correct. Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma." }

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

{ "text_length": 5871 }

{ "text": "HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed." }

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

{ "text_length": 2956 }

{ "text": "CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:, None.,MEDICATIONS:, None.,FAMILY HISTORY:, Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:, None.,SOCIAL HISTORY: , The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:, The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia." }

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

{ "text_length": 1528 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, 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. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the \"Scotty Dog,\" After obtaining the \"Scotty Dog\" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the \"Scotty Dog\" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis." }

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

{ "text_length": 3090 }

{ "text": "PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS: ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy. ,INDICATIONS: ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy. He has had previous colonoscopy. There is no family history of bleeding, no current problems with his bowels. On examination, he has internal hemorrhoids. His prostate is enlarged and increased somewhat in firmness. He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm. These were removed with snare polypectomy technique. I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation. Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%. A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve. The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port. The scope was withdrawn into the left transverse colon, where the second polyp was identified. It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well. The scope was then gradually withdrawn the remaining distance and removed. The patient tolerated the procedure well." }

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

{ "text_length": 1946 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note." }

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

{ "text_length": 2904 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS: ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1. Left axillary dissection with incision and drainage of left axillary mass.,2. Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:, Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS: ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses. Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter. The patient had been continued on antibiotics preoperatively. The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time. Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses. The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time. The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete. A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass. Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis. Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature. Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture. Upon revaluation of the incisional site, it was noted to be hemostatic. Warm lap sponge was then left in place at this site. Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction. This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation. This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch. Steri-Strips were applied. Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision. This was placed within the incision site, ________ drainage of the axillary potential space. Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique. Steri-Strips and sterile dressings were applied. JP bulb was then placed to suction and sterile dressings were applied to both axilla. The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition. He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise." }

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

{ "text_length": 4189 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications." }

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

{ "text_length": 3875 }

{ "text": "PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat. The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat. The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted. The patient was sent to the recovery room in good condition, having tolerated the procedure well." }

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

{ "text_length": 1741 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE: ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.," }

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

{ "text_length": 1618 }

{ "text": "Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.,REST ECHO:, EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.,IMPRESSION:,1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2. Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure." }

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

{ "text_length": 1325 }

{ "text": "GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:" }

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

{ "text_length": 166 }

{ "text": "CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving her vehicle at approximately 40 miles per hour. The patient was driving a minivan. The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. The patient states that she was wearing her seatbelt. She was driving. There were no other passengers in the van. The patient states that she was restrained by the seatbelt and that her airbag deployed. The patient denies hitting her head. She states that she does have some mild pain on the left aspect of her neck. The patient states that she believes she may have passed out shortly after the accident. The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. The patient denies any pain in her knees, ankles, or feet. She denies any pain in her shoulders, elbows, and wrists. The patient does state that she is somewhat painful throughout the bones of her pelvis as well. The patient did not walk after this accident. She was removed from her car and placed on a backboard and immobilized. The patient denies any chest pain or difficulty breathing. She denies any open lacerations or abrasions. The patient has not had any headache, nausea or vomiting. She has not felt feverish or chilled. The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. There were no oblique vectors or force placed on this accident. The patient had straight rear-ending of the vehicle in front of her. The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. The patient states that her last menstrual cycle was at the end of May. She does not believe that she could be pregnant. She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:, No significant medical history other than acne.,PAST SURGICAL HISTORY:, None.,SOCIAL HABITS: , The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:, Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: This is a Hispanic female who appears her stated age of 32 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant. She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar. The patient is without capsular retractions, labored respirations or accessory muscle usage. She responds well and spontaneously.,VITAL SIGNS: Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT: Head is normocephalic. There is no crepitus. No bony step-offs. There are no lacerations on the scalp. Sclerae are anicteric and noninjected. Fundoscopic exam appears normal without papilledema. External ocular movements are intact bilaterally without nystagmus or entrapment. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesions.,NECK: Supple. No thyromegaly. No JVD. No carotid bruits. Trachea is midline. There is no stridor.,HEART: Regular rate and rhythm. Clear S1 and S2. No murmur, rub or gallop is appreciated.,LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.,ABDOMEN: Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants. There is no organomegaly here. Positive bowel sounds are auscultated throughout. There is no rigidity or guarding. Negative CVA tenderness bilaterally.,EXTREMITIES: No edema. There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR: Capillary refill is less than two seconds in all extremities. The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC: Alert and oriented to person, place, and time. The patient recalls all events regarding the accident today.,NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated. The patient has equal and strong distal and proximal muscle group strength in all four extremities. The patient has negative Romberg and negative pronator drift.,LYMPHATICS: No appreciable adenopathy.,MUSCULOSKELETAL: The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists. There are no bony abnormalities identified. The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN: Warm, dry, and intact. No lacerations. There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus. No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done. There is an x-ray of the pelvis, which shows normal pelvis and right hip. There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine. There is some prevertibral soft tissue swelling from C5 through C7. This is nonspecific and could be due to prominence of upper esophageal sphincter. The CT scan of the brain without contrast shows no evidence of acute intracranial injury. There is some mucus in the left sphenoid sinus. The patient also has emergent CT scan without contrast of the abdomen. The initial studies show some dependent atelectasis in both lungs. There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated. A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities. The patient has laboratory studies done as well. CBC is within normal limits without anemia, thrombocytopenia or leukocytosis. The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations.,ASSESSMENT AND PLAN:, Multiple contusions and abdominal pain, status post motor vehicle collision. Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans. She has normal scans of the brain and her C-spine as well. The patient is in stable condition. She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting. The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain." }

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

{ "text_length": 7749 }

{ "text": "ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:, The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:, The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:, The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:, The patient was discharged home.,DISCHARGE INSTRUCTIONS:, His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge." }

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

{ "text_length": 3609 }

{ "text": "CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. She complained of a headache. She was able to walk. She continued to participate in her flag practice. She got dizzier. She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:, DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home. There is no smoking at home. There is second-hand smoke exposure.,FAMILY HISTORY: ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:, She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS: ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL: She is supine awake, alert, cooperative, and active child.,HEENT: Head atraumatic, normocephalic. Pupils equal, round, reactive to light. Extraocular motions intact and conjugate. Clear TMs, nose and oropharynx. Moist oral mucosa without noted lesions.,NECK: Supple, full painless nontender range motion.,CHEST: Clear to auscultation, equal, stable to palpation.,HEART: Regular without rubs or murmurs.,ABDOMEN: No abdominal bruits are heard.,EXTREMITIES: Equal femoral pulses are appreciated. Equal radial and dorsalis pedis pulses are appreciated. He moves all extremities without difficulty. Nontender. No deformity. No swelling.,SKIN: There was no significant bruising, lesions or rash about her abdomen. No significant bruising, lesions or rash.,NEUROLOGIC: Symmetric face and extremity motion. Ambulates without difficulty. She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:, The differential entertained includes head injury, anxiety, and hypertensive emergency. She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. Her laboratory data shows a mildly elevated creatinine of 1.3. Urine is within normal. Urinalysis showing no signs of infection. Head CT read by staff has no significant intracranial pathology. No mass shift, bleed or fracture per Dr. X. A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. No significant ST-T wave changes. No significant change from previous 09/2007 EKG. Her headache has resolved. She is feeling better. I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home. Follow up with her regular doctor. Blood pressures have normalized for her. She should return to emergency department on concern. They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope." }

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

{ "text_length": 3568 }

{ "text": "CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of \"chest pain\".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:, All other systems reviewed & are negative.,PAST MEDICAL HISTORY:, Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates" }

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

{ "text_length": 2193 }

{ "text": "CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray. He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion. Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock. A ring block was also done using another 0.3 mL of lidocaine. Glucose water is also used for anesthesia. After several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus. The blunt probe was then introduced again with care taken to avoid the meatus. After initial adhesions were taken down the straight clamp was introduced to break down further adhesions. Care was taken to avoid the frenulum. The clamps where then repositioned at 12 and 6 o'clock. The Mogen clamp was then applied with a dorsal tilt. After the clamp was applied for 1 minute the foreskin was trimmed. After an additional minute the clamp was removed and the final adhesions were taken down. Patient tolerated the procedure well with minimal bleeding noted. Patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,Routine care discussed with the family. Need to clean the area with just water initially and later with soap and water or diaper wipes once healed." }

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

{ "text_length": 1273 }

{ "text": "CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode." }

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

{ "text_length": 3600 }

{ "text": "PROCEDURE: ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze. Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions. Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus. Saccadic movements did not reveal any evidence of dysmetria or overshoot. Sinusoidal tracking was performed well for the patient's age. Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands. Therefore adequate OKNs were not achieved. The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again. The patient complained of severe dizziness in this position. There was no clear-cut decremental response with repetition. In the head hanging left position, no significant nystagmus was identified. Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position. No other significant nystagmus was noted. There was no evidence of clear-cut caloric stimulation abnormality. This study would be most consistent with a right vestibular dysfunction." }

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

{ "text_length": 1948 }

{ "text": "PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day." }

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

{ "text_length": 1556 }

{ "text": "PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with Betadine. The patient was given sedation and monitored. Under fluoroscopy, the right sacral alar notch was identified. After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained. Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected. Coagulation was then carried out at 90oC for 90 seconds. The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint. Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications. The patient was returned to outpatient recovery in stable condition." }

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

{ "text_length": 1158 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system." }

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

{ "text_length": 10672 }

{ "text": "REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES: Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY: No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs. **No history of OB/GYN problems.,MUSCULOSKELETAL: Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: See psychiatric evaluation.,ENDOCRINE: No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities." }

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

{ "text_length": 1608 }

{ "text": "PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct." }

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

{ "text_length": 2954 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,PROCEDURE PERFORMED:,1. Third metatarsal osteotomy, right foot.,2. Talus bunionectomy, right foot.,3. Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal. In addition, she complains of a painful right talus bunion to the right foot. She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. The risks versus benefits of the procedure have been explained to the patient by Dr. X and 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. She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction. Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type 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. Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area. There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head. A previous cicatrix was noted with slight hypertrophic scarring. Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length. Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen. Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue. Any small traversing veins were ligated with electrocautery. Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue. Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified. A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues. Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal. McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed. A moderate amount of plantar adhesions were encountered. The third toe was plantar flex and the third metatarsal was delivered into the wound. Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw. The metatarsal head was allowed to float. The wound was flushed with copious amounts of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained. Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique. Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal. There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively. A #10 blade was used to make a 3 cm incision through the skin. Next, a #15 blade was used to deepen the incision through the subcutaneous tissue. Next, the medial and lateral aspects were undermined. The abductor tendon was identified and retracted. A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone. The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis. A reciprocating rasp was used to smooth all bony prominences. The wound was flushed with copious amount of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues. #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture. Next, #4-0 nylon was used to close the skin in a simple interrupted technique. Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head. A #15 blade was used to make a small linear incision under the third metatarsal head. The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa. The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee. Copious amounts of Webril were placed on all bony prominences. 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast. One was able to insert two fingers to the distal and proximal aspects of the _cast. The capillary refill time to the digits was less than three seconds after cast application. The patient tolerated the above anesthesia and procedures without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given standard postoperative instructions to rest, ice and elevate her right foot. She was counseled on smoking cessation. She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain. She was given Keflex #30 1 p.o. t.i.d. She is to follow up with Dr. X on Monday. She is to be full weightbearing with a cast boot. She was given emergency contact numbers to call us if problem arises." }

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

{ "text_length": 6514 }

{ "text": "CHIEF COMPLAINT:, The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:, Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES: ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Depression.,3. Myofascitis of the feet.,4. Severe osteoarthritis of the knee.,5. Removal of the melanoma from the right thigh in 1984.,6. Breast biopsy in January of 1997, which was benign.,7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998.,8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:, The patient is married. She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:, As per the HPI.,PHYSICAL EXAMINATION:,General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities: Revealed no edema.,Neurologic: Grossly intact.,RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1. Hypertension, well controlled.,2. Family history of cerebrovascular accident.,3. Compression fracture of L1, mild.,4. Osteoarthritis of the knee.,5. Mildly abnormal chest x-ray.,PLAN:,1. We will get a C-reactive protein cardiac.,2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain.,3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection." }

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

{ "text_length": 4609 }

{ "text": "PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:, The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name: Sigma, model #: 12345, serial #: 123456.,VENTRICLE LEAD:, Model #: 12345, the ventricular lead serial #: 123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:, Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS: ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well. There was no complications. The patient went to recovery in stable condition. Chest x-ray will be ordered. She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care. If you have any questions or concerns, please feel free to contact." }

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

{ "text_length": 3989 }

{ "text": "DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care." }

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

{ "text_length": 1668 }

{ "text": "CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:, The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia. A Storz urethrotome sheath was inserted into the urethra under direct vision. Visualization revealed a stricture in the bulbous urethra. This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder. Visualization revealed no other lesions in the bulbous or membranous urethra. Prostatic urethra was normal for age. No foreign bodies, tumors or stones were seen within the bladder. Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition." }

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

{ "text_length": 946 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case." }

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

{ "text_length": 4711 }

{ "text": "EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis. Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:, Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava. Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina. Sternotomy wires are noted. They appear in appropriate placement. There are no focal areas of consolidation to suggest pneumonia. Once again seen is minimal amount of bilateral basilar atelectasis. The cardiomediastinal silhouette appears to be within normal limits at this time. No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1. There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2. Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3. Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique." }

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

{ "text_length": 1259 }

{ "text": "ADMISSION DIAGNOSIS:, Morbid obesity. BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity. BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years. She has made multiple attempts at nonsurgical weight loss without success. She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate. She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure. She tolerated without difficulty. She was admitted to the floor post procedure. Her postoperative course has been unremarkable. On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty. She has ambulated and had no complaints. Today, on postoperative day 2, the patient continues to do well. Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet. At this point, it is felt that she is stable for discharge. Her drain was discontinued.,DISCHARGE INSTRUCTIONS:, Liquid diet x1 week, then advance to pureed and soft as tolerated. No heavy lifting, greater than 10 pounds x4 weeks. The patient is instructed to not engage in any strenuous activity, but maintain mobility. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic pain medicine. She may shower. She needs to keep her wounds clean and dry. She needs to follow up in my office in 1 week for postoperative evaluation. She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain. She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:, She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace." }

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

{ "text_length": 2054 }

{ "text": "PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications." }

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

{ "text_length": 2448 }

{ "text": "EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE." }

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

{ "text_length": 379 }

{ "text": "ALLOWED CONDITIONS:, Lateral epicondylitis, right elbow,EMPLOYER:, ABCD,REQUESTED ALLOWANCE:, Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars. He does state he was employed for such company for the last five years. His work includes lots of pulling, pushing, and working in weird angles. He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger. He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility. He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger. He was placed on light duty for the next couple of months. Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007. He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007. Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome. He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008. It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition. The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger. There are times when the whole hand becomes very numb. He does not use and do any type of lifting with regards to the right hand secondary to the discomfort. His pain does vary between a 4 on a scale of 1 to 10. He denies any weakness. He does not awaken at night with the symptomatology. Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms. He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand. He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:, Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:, Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds. He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis. The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees. Tinel's and Phalen's tests were positive. Reverse Phalen's test was negative. There is diminished sensation in distribution of the thumb, index, middle, and ring finger. The intrinsic function did appear to be intact. The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow. The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees. Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW: ,1. First report of injury, difficulty as related to both hands.,2. Number of notes of Occupational Health Clinic. It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3. December 20, 2007, operative note of Dr. Y. At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4. November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009. Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region. It also should be noted that really there is no significant weakness as related to the function of the right upper extremity. Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION: ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER: ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis. This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION: ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing. Please explain.,ANSWER: ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing. As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION: ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement. Please also give an estimated time for maximum medical improvement.,ANSWER: ,The injured worker has indeed reached maximum medical improvement as related to the elbow. There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis. At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION: ,Is the claimant suffering from carpal tunnel syndrome, right?" }

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

{ "text_length": 7221 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night. He denies any pain, nausea, vomiting or diarrhea. In the ER, a Foley catheter was placed and was irrigated with saline. White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9. Urine culture is pending. Chest x-ray is pending. His UA did show lots of red cells. The patient currently is comfortable. CBI is running. His urine is clear.,PAST MEDICAL HISTORY:,1. Hypertension.,2. High cholesterol.,3. Bladder cancer.,4. Bilateral total knee replacements.,5. Cataracts.,6. Enlarged prostate.,ALLERGIES:, SULFA.,MEDICATIONS AT HOME:,1. Atenolol.,2. Cardura.,3. Zegerid.,4. Flomax.,5. Levaquin.,6. Proscar.,7. Vicodin.,8. Morphine.,9. Phenergan.,10. Ativan.,11. Zocor.,12. Prinivil.,13. Hydrochlorothiazide.,14. Folic acid.,15. Digoxin.,16. Vitamin B12.,17. Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter. He does not smoke, occasionally drinks alcohol. He is independent with his activities of daily living.,REVIEW OF SYSTEMS:, Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL: An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS: BP of 162/60 and pulse oximetry of 98% on room air.,HEENT: Pink conjunctivae. Anicteric sclerae. Oral mucosa is moist.,NECK: Supple.,CHEST: Clear to auscultation.,HEART: Regular S1 and S2.,ABDOMEN: Soft and nontender to palpation.,EXTREMITIES: Without edema.,He has a Foley catheter in place. His urine is clear.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Hematuria." }

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

{ "text_length": 1963 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well." }

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

{ "text_length": 1125 }