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{ "text": "REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well. He has a relatively unremarkable foreskin. At this point in time, he otherwise seems to be doing reasonably well. The question is about the foreskin. He otherwise has no other significant issues. Severity low, ongoing since birth two weeks. Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:, Male exam. Normal and under the penis, report normal uncircumcised 2-week-old. He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe. I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision. This kid should otherwise do reasonably well.,PLAN: ,Follow up as needed. But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision." }

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

{ "text_length": 1161 }

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

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

{ "text_length": 4620 }

{ "text": "PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax. The shoulder was then prepped and draped in the usual sterile fashion. We then injected the glenohumeral joint with 60 cc of sterile saline solution. A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution. An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition. The biceps was found to be intact. There was a SLAP tear noted just posterior to the biceps. Pictures were taken. No Bankart or Hill-Sachs lesions were noted. The rotator cuff was examined and there were no undersurface tears. Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff. A drill hole was made and then knotless suture anchor was placed to repair this. Pictures were taken. We then washed out the joint with copious amounts of sterile saline solution. It was drained. Our 3 incisions were closed using 3-0 nylon suture. A pain pump catheter was introduced into the shoulder joint. Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition. I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care." }

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

{ "text_length": 2046 }

{ "text": "REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:, Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses. Ears, nose, mouth and throat. The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY: ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps. No joint or muscle pain. No muscle weakness or tenderness. No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS: ,The patient denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC: ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC: ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity." }

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

{ "text_length": 3177 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION:," }

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

{ "text_length": 125 }

{ "text": "CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision \"greyed out\" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were \"unremarkable.\" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly \"unremarkable.\",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: , ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or \"gray outs\" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96." }

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

{ "text_length": 6338 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left hip. Subsequently fell injuring her left shoulder. It's unclear how long she was on the floor. She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted. Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only. She presently is complaining of pain to the left shoulder. She states she also has pain to the hip with motion of the leg. She denies any numbness or paresthesias. She states prior to this, she was relatively active within her home. She does care for her daughter who has a mess. The patient denies any other injuries. Denies back pain.,PREVIOUS MEDICAL HISTORY:, Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:, Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1. PENICILLIN.,2. SULFA.,3. ACE INHIBITOR.,PRESENT MEDICATIONS,1. Lipitor 20 mg q.d.,2. Metoprolol 25 mg b.i.d.,3. Plavix 75 mg once a day.,4. Aspirin 325 mg.,5. Combivent Aerosol two puffs twice a day.,6. Protonix 40 mg q.d.,7. Fosamax 70 mg weekly.,8. Multivitamins including calcium and vitamin D.,9. Hydrocortisone.,10. Nitroglycerin.,11. Citalopram 20 mg q.d.,SOCIAL HISTORY:, She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:, Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL: The patient is alert and responsive.,EXTREMITIES: The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment. She is diffusely tender over the proximal humerus. She is unable to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the MP and IP joints of both hands. The left lower extremity, the thigh compartment is supple. She has pain with log rolling tenderness over the greater trochanter. The patient has pain with any attempt at hip flexion passively or actively. The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism. She has 2 to 3+ bilateral pitting edema pretibially and pedally. The patient has a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:, Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture. There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine. There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets. Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62. Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1. This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip. The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2. Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:, I have discussed this case with the emergency room physician as well as the patient. Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure. She will need cardiology clearance, which would include an echo in advance of the procedure. I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter. She presently understands and agrees with the plan." }

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

{ "text_length": 5553 }

{ "text": "HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are now averaging about three times per week. They are generally on the very top of the head according to the patient. Interestingly, she denies any previous significant history of headaches prior to this. There has been no nausea associated with the headaches. The patient does note that when she speaks on the phone, the left ear has \"weird sounds.\" She feels a general fullness in the left ear. She does note pulsation sounds within that left ear only. This began on February 17th according to the patient. The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family. The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. Interestingly, there has been no significant drop or change in her hearing. She does report she has had dizzy episodes in the past with nausea, being off balance at times. It is not associated with the pulsations in the ear. She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. She is denying any vision changes. The headaches are listed as moderate to severe in intensity on average about three to four times per week. She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Hypercholesterolemia.,PULMONARY: Negative.,GASTROINTESTINAL: Pertinent for nausea.,GENITOURINARY: The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC: History of dizziness and the headaches as listed above.,VISUAL: Negative.,DERMATOLOGIC: History of itching. She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:, She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:, Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married. She works at Eye Center as a receptionist. She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS: Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL: The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: There is an old mastoidectomy scar, left ear. The ear canals are clean and dry. Drums intact and mobile. Weber exam is midline. Grossly hearing is intact. Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL: Reveals clear drainage. Deviated nasal septum to the left, listed as mild to moderate. Ostiomeatal complexes are patent and turbinates are healthy. There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. See fiberoptic nasopharyngoscopy separate exam.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: ,1. Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. Consider, also normal pressure hydrocephalus.,2. Recurrent headaches.,3. Deviated nasal septum.,4. Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet. I have also ordered a carotid ultrasound study as part of the workup and evaluation. She has had a recent CAT scan of the brain though this was without contrast. It did reveal previous mastoidectomy, left temporal bone, but no other mass noted. I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related. Hearing protection devices should be used at all times as well. I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. I am going to recheck her in three weeks. If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. She will be scheduled for a audio and tympanogram to be done as well prior to that procedure." }

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

{ "text_length": 6270 }

{ "text": "CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:, This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:, The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1. The overall quality of the study is fair.,2. The left ventricular cavity appears to be normal on the rest and stress studies.,3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4. The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease." }

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

{ "text_length": 1371 }

{ "text": "PREOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:, Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:, Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:, General.,HISTORY: , The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.,PROCEDURE:,: Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B. I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum. On the right side, I took out some impacted wax and removed the rock with a large suction. It was actually resting on the surface of the drum but had not scarred or damaged the drum. The drum was intact with no evidence of middle ear fluid. The microscope was set aside. Afrin drops were placed in both nostrils. The neck was gently extended and the Crowe-Davis mouth gag inserted. The tonsils and adenoids were very large. The uvula was intact. Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx. Tonsillectomy accomplished by sharp and blunt dissection. Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine. Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds. Sponge is removed from the nasopharynx. The suction electrocautery was used for pinpoint hemostasis on the adenoid bed. We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices. The nose and throat were then irrigated with saline and suctioned. Excellent hemostasis was observed. An orogastric tube was placed. The stomach found to be empty. The tube was removed, as was the mouth gag. Sponge and needle count were reported correct. The child was then awakened and prepared for her to return to the recovery room. She tolerated the operation excellently." }

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

{ "text_length": 2445 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size. There were no adnexal masses appreciated. The vulva and perineum appeared normal. Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally. There was a functional cyst on the left ovary. There was filmy adhesion in the left pelvic sidewall. There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac. The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis. The liver was visualized and appeared normal. The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization. She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. She was then prepped and draped and placed in the dorsal lithotomy position. A bimanual exam was performed and the above findings were noted. Prior to beginning the procedure, her bladder was drained with a red Robinson catheter. A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum. The cervix was dilated so that the uterine elevator could be placed. Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made. The Veress needle was then inserted and using sterile saline ______ the pelvic cavity. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope. A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty. Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube. A second Hulka clip was then placed across the entire diameter just proximal to this. There was good hemostasis at the fallopian tube. The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle. A second Hulka clip was placed just distal to this again across the entire diameter. Good hemostasis was obtained. At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic. The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed. The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl. The suprapubic incision was then closed with Steri-Strips. The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic. The patient tolerated that procedure well. The sponge, lap, and needle counts were correct x2. She will follow up postoperatively for followup care." }

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

{ "text_length": 3848 }

{ "text": "CHIEF COMPLAINT: ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin. He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago. The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103. He was seen at Hospital, transferred to Children's Hospital for further care. Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant. He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother. I was requested a consultation by Dr. X because of the appearance of penis. The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies. He was a term delivery via vaginal delivery. Surgeries; he has had 2 circumcisions. No other hospitalizations. He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned. He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings. There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment. Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight is 14.9 kg.,GENERAL: The patient was sleepy but easily arousable.,HEAD AND NECK: Grossly normal. His neck and chest are without masses.,NARES: He had some crusted nares; otherwise, no other discharge.,LUNGS: Clear.,CARDIAC: Without murmurs or gallops.,ABDOMEN: Soft without masses or tenderness.,GU: He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema. There was some induration around the penis; however, there were no signs of active infection. He has a buried appearance of the penis after recent circumcision with a normal appearing glans. The tissue itself, however, was quite dull and is soft or readily retractable at this time. The scrotum was normal, and there was no erythema, there was no tenderness. Both testes were descended without hydroceles.,EXTREMITIES: He has full range of motion of all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,BACK: Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis. This is being treated, but it is most likely Staph and pending sensitivities. I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad. I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day. I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely. Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so. He has a scheduled followup appointment with his urologist and he should keep that appointment or followup sooner if there is any other problem arising." }

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

{ "text_length": 4087 }

{ "text": "EXAM:, Single frontal view of the chest.,HISTORY:, Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:, Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:, A single frontal view of the chest was evaluated. It reveals interval placement of an ET tube and an NG tube. ET tube is midway between the patient's thoracic inlet and carina. NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm. There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions. The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique. There is a slight increase seen with regards to the central pulmonary vessels. Again, this may represent a minimal amount of pulmonary vascular congestion. There is paucity of bowel gas seen in the upper abdomen. The osseous thorax appears to be grossly intact and symmetrical. Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1. No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2. Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3. Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion." }

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

{ "text_length": 1524 }

{ "text": "EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium. There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology. There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid. Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance. There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant. There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis. The small and large bowels are otherwise unremarkable. The stomach is grossly unremarkable. There is no abdominal or retroperitoneal adenopathy. There are no adrenal masses. The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance. The spleen contains several small calcified granulomas, but no evidence of masses. It is normal in size. The lung bases are clear bilaterally. The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1. Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2. Multiple uterine fibroids.,3. Prominent endometrium.,4. Followup pelvic ultrasound is recommended." }

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

{ "text_length": 1703 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL: ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case." }

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

{ "text_length": 2960 }

{ "text": "VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:, Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:, Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI nondisplaced. Chest wall unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.,BREASTS:, In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.,BACK:, Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:, Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age." }

[ { "label": " Office Notes", "score": 1 } ]

{ "text_length": 1959 }

{ "text": "HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. She was also noted to have periodic breathing. The patient is breast and bottle-fed and has been feeding well. There has been no diarrhea or vomiting. Voiding well. Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section. Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa. The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL: The patient is icteric, well hydrated. Does have periodic breathing. Color is pink and also icterus is noted, scleral and skin.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular with a soft 3/6 murmur. Femorals are well palpable. Cap refill is immediate,ABDOMEN: Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA: Those of a female child.,SKIN: Color icteric. Nonspecific rash on the body, which is sparse. The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES: The patient moves all extremities well. Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen. Parents were made aware of the fact that child did have a murmur. I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. Total bilirubin was 25.4 mg, all of which was unconjugated. CRP was 0.3 mg%. Blood culture was drawn. Catheterized urine specimen was normal. Parents were kept abreast of what was going on all the time and the need for admission. Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:, Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect." }

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

{ "text_length": 3354 }

{ "text": "PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care." }

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

{ "text_length": 4203 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV general mask airway.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia. The patient was placed on the operating table in supine position. After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction. After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma. A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents. A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep. Cortisporin Otic drops were placed followed by cotton balls. Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed. The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane. The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels. A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep. After this, the patient had Cortisporin Otic drops followed by cotton balls placed. The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well. The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears." }

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

{ "text_length": 2581 }

{ "text": "CHIEF COMPLAINT:, Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:, The patient is on my schedule today to explore treatment of the above complaints. She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count. She says she has just finished a series of 10 radiation treatments for pain relief. She states she continues to have significant pain symptoms. Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee. She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times. She complains of some diffuse, mid back pain. She describes the pain as sharp, dull, and aching in nature. She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain. She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking. She is on significant doses of narcotics. She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:, Significant for cancer as above. She also has a depression.,PAST SURGICAL HISTORY:, Significant for a chest port placement.,CURRENT MEDICATIONS:, Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet. She does not know of what strength up to eight daily. She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent. She is on Neurontin 300 mg three times daily.,HABITS:, She smokes one pack a day for last 30 years. She drinks beer approximately twice daily. She denies use of recreational drugs.,SOCIAL HISTORY:, She is married. She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:, Significant mainly for her pain complaints. For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General: Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs: Height is 5 feet 2 inches. Weight is 130 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Chest: Clear to auscultation.,Heart: Regular rate and rhythm.,Abdomen: Soft, regular bowel sounds.,Musculoskeletal: Examination shows functional range of joint movements. No focal muscle weakness. She is deconditioned.,Neurologic: She is alert and oriented with appropriate mood and affect. The patient has normal tone and coordination. Reflexes are 2+ in both knees and absent at both ankles. Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine: Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement. The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally. She has had increased uptake in the sacroiliac joint regions bilaterally. CT of the chest showed no evidence of recurrent metastatic disease. CT of the abdomen showed no evidence of metastatic disease. MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs. CT of the pelvis showed a trabecular pattern with healed metastases. CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan. MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2. Symptomatic facet and sacroiliac joint syndrome on the right.,3. Chronic pain syndrome.,RECOMMENDATIONS:, Dr. XYZ and I discussed with the patient her pathology. Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right. Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today. I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed. She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this. We have asked for stat protime today. She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications. She is on significant dose of narcotics already, however, she continues to have pain symptoms. Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed. I will plan on evaluating her in the Clinic on Tuesday. I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead. She voiced understanding and is in agreement with this plan. I have also asked her to get an x-ray of the lumbar spine for further evaluation. Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings. Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments." }

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

{ "text_length": 5855 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2." }

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

{ "text_length": 62 }

{ "text": "SUBJECTIVE:, This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap. Last Pap was a year ago and normal. LMP was 08/29/2004. Her cycles are usually regular, although that one came about a week early. Her husband has had a vasectomy. Overall, she is feeling well.,Health history form was reviewed. There has been no change in her personal history. She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again. Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables. Right now, she is not doing nearly as well. She has perhaps two dairy servings daily, trying to cut down. She is not exercising at all and fruit and vegetable intake varies. She is a nonsmoker. Last cholesterol was in 2003 and was normal. She had a mammogram which was normal recently. She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT: She feels as though she may have some allergies at night. Most of her symptoms occur then, not during the day. She will wake up with some congestion, sneezing, and then rhinorrhea. Currently, she uses Tylenol Sinus. Today, her symptoms are much better. We did have rain this morning.,Respiratory and CV: Negative.,GI: She tends to have a little gas which is worse when she is eating more fruits and vegetables. She had been somewhat constipated but that is better.,GU: Negative.,Dermatologic: She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint. It was very sensitive to water. It seems to be slowly improving.,OBJECTIVE:,Vital Signs: Her weight was 154 pounds, which is down 2 pounds. Blood pressure 104/66.,General: She is a well-developed, well-nourished, pleasant white female in no distress.,Neck: Supple without adenopathy. No thyromegaly or nodules palpable.,Lungs: Clear to A&P.,Heart: Regular rate and rhythm without murmurs.,Breasts: Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen: Soft without organomegaly, masses, or tenderness.,Pelvic: Reveals no external lesions. The cervix is parous. Pap smear done. Uterus is anteverted and normal in size, shape, and consistency, and nontender. No adnexal enlargement.,Extremities: Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1. Normal GYN exam.,2. Rhinitis, primarily in the mornings. Vasomotor versus allergic.,3. Eczematous dermatitis on right third finger.,PLAN:,1. Discussed vasomotor rhinitis. I suggested she try Ayr Nasal saline gel. Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2. Exam with Pap annually.,3. Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4. Discussed nutrition and exercise. I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week." }

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

{ "text_length": 3129 }

{ "text": "FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:, BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed." }

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

{ "text_length": 1278 }

{ "text": "REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman. The patient had shortness of breath over the last few days, progressively worse. Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea. Coronary artery disease workup many years ago. He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:, Married, ex-smoker, and does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness. The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, tiredness.,HEENT: No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL: Some frequency, urgency, no hematuria.,MUSCULOSKELETAL: Arthritis, muscle weakness.,SKIN: Chronic skin changes.,CNS: History of TIA. No CVA, no seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PSYCHOLOGICAL: No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits. First set of cardiac enzymes profile negative. BNP 4810.,Chest x-ray confirms unremarkable findings. EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:" }

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

{ "text_length": 2778 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:, None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:, Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body. This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:, The patient was placed under general endotracheal anesthesia. The abdomen was prepped and draped in the usual fashion. Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters. I was able to remove additional disk space and score the vertebral bodies. The rest of the disk removal was done with the curette, scraping the endplates. I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place. We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side. This was filled with bone and BMP as well. Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws. Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness. He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc. MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5. A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic. An anterior lumbar interbody fusion was suggested. Procedure, risks, and complications were explained." }

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

{ "text_length": 2768 }

{ "text": "INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid." }

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

{ "text_length": 2144 }

{ "text": "PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:, After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. The sac was cleared of overlying adherent tissue, and the fascial defect was delineated. The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect. The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures. The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The skin was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition." }

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

{ "text_length": 1384 }

{ "text": "EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation." }

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

{ "text_length": 1085 }

{ "text": "DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal. Transesophageal echocardiogram July 27, 2007, that was normal. No evidence of vegetations. CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. There were 2-3 additional tiny cysts in the right lobe. The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers. For further details of the admission, please see the previously dictated history and physical. ,HOSPITAL COURSE:, Gram-negative rod bacteremia. The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers. The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah. Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet. The patient, however, appeared to be responding well to levofloxacin. I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime. Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. In addition, I told the patient that it would be my recommendation to get rid of the rats. I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. I told her very clearly that she should, indeed, get rid of the animals. The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following., ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated. Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases. I gave the patient the phone number to call on Monday for an appointment. Additional followup is also with Dr. XYZ, her primary care physician. Please note that 40 minutes was spent in the discharge." }

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

{ "text_length": 3694 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:, Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:, This patient has been experiencing difficulty with eyesight regarding activities of daily living. There has been a progressive and gradual decline in the visual acuity. The cataract was believed related to her decline in vision. The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail. The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery. The possibility of needing intraocular lens exchange or incorrect lens power was discussed. Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed. It was explained that some or all of these complications might arise at the time of or months to years after surgery. The patient had a good understanding of the risks with the proposed, elective eye surgery. The patient accepted these risks and elected to proceed with cataract surgery. All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. The pupil was dilated per protocol. The patient was taken to the operating room and placed in the supine position. After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage. No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion. An eyelid speculum was used to separate the eyelids. A crescent blade was used to make a clear corneal temporally located incision. A 1-mm Dual-Bevel blade was used to make a paracentesis site. The anterior chamber was filled with viscoelastic (Viscoat). The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision. A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision. A 25-gauge pre-bent cystotome used to begin a capsulorrhexis. The capsulorrhexis was completed with the Utrata forceps. A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted. The lens was able to be freely rotated within the capsular bag. Divide-and-conquer ultrasound was used for phacoemulsification. After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment. Each of the four nuclear quadrants was phacoemulsified. Aspiration was used to remove all remaining cortex. Viscoelastic was used to re-inflate the capsular bag. An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag. The trailing haptic was placed with the Sinskey hook. The lens was made well centered and stable. Viscoelastic was aspirated. BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure. A Weck-Cel sponge was used to check both incision sites for leaks and none were identified. The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens. The eyelid speculum was removed and the patient was cleaned free of Betadine. Vigamox and Econopred drops were applied. A soft eye patch followed by a firm eye shield was taped over the operative eye. The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed. All questions were answered. The discharge instructions were also reviewed with the patient by the discharging nurse. The patient was comfortable and was discharged with followup in 24 hours. Complications none." }

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

{ "text_length": 4682 }

{ "text": "CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of \"startle response (myoclonic movement of the shoulders)\" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia." }

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

{ "text_length": 3425 }

{ "text": "CHIEF COMPLAINT:, Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis. He has had severe global developmental delay, and is nonverbal. He can follow objects with his eyes, but has no ability to interact with his environment to any great degree. He has noted if any purposeful use of the hands. He has abnormal movements constantly, which are more choreiform and dystonic. He has spastic quadriparesis, which is variable at times. The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms. I began seeing him at 20 months of age. At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms. The patient had benefit from this medication, and was doing well at that time with regard to that seizure type. He initially was on phenobarbital, which failed to give him benefit. He continued on phenobarbital; however, for a long period time thereafter. The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly. Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense. It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day. These events manifest as tonic spells with eye deviation and posturing. Mother reports flexion of the upper extremities, extension with lower extremities. During that time, he is not able to cry or say any sounds. These events last from seconds to minutes, and occur at least multiple times per week. There are times where he has none for a few days and other times where he has multiple days in a row with events. He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. He may vomit after these episodes, then seems to calm down. It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:, The patient's medications include Lamictal for a total of 200 mg twice a day. It is a 150 mg tablet and 25 mg tablets. He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day. He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias. No respiratory or cardiovascular complaints. He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: The patient is a slender male who is microcephalic. He has EEG electrodes in place and is on the video EEG at that time.,HEENT: His oropharynx shows no lesions.,NECK: Supple without adenopathy.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs.,ABDOMEN: Benign with G-tube in place.,EXTREMITIES: Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL: The patient is alert and has bilateral esotropia. He is able to fix and follow objects briefly. He is unable to reach for objects. He exhibits constant choreiform movements when excited. These are more prominent in the upper extremities and lower extremities. He has some dystonic posture with flexion of the wrist and fingers bilaterally. He also has plantar flexion at the ankles bilaterally. His cranial nerves reveal that his pupils are equal, round, and reactive to light. Extraocular movements are intact other than bilateral esotropia. His face moves symmetrically. Palate elevates in midline. Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above. He has clonus at the ankles bilaterally, and some valgus contracture of the ankles. His sensation is intact to light touch bilaterally. Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy. He has microcephaly as well as dystonic cerebral palsy. He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort. He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types. He will remain hospitalized for probably at least 48 hours to 72 hours. He could be discharged sooner if multiple events are captured. His medications, we will continue his current dose of Zonegran and Lamictal for now. Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge." }

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

{ "text_length": 5434 }

{ "text": "CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:, BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately." }

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

{ "text_length": 2591 }

{ "text": "HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.,EYES: Conjunctivae are now pink.,ENT: Oropharynx is clear.,CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.,LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN: Soft and nontender with no organomegaly appreciated.,EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.,NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:, Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes." }

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

{ "text_length": 4684 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:, Stable, extubated, to PACU.,PROCEDURE IN DETAIL:, Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver." }

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

{ "text_length": 5776 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease. It was carried sharply down to the transverse wrist crease. The transverse carpal ligament was identified and released under direct vision. Proximal to the transverse wrist crease it was released subcutaneously. During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch. The nerve appeared to be mildly constricted. Closure was routine with running 5-0 nylon. A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition." }

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

{ "text_length": 1319 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,management of respiratory depression with other medical complications. The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter. In addition, he also developed cardiac complications including atrial fibrillation. The patient was evaluated by the cardiologist as well as the pulmonary service and Urology. He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008. He subsequently underwent cardiac arrest and he was resuscitated at that time. He was intubated and placed on mechanical ventilatory support. Subsequent weaning was unsuccessful. He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1. Albuterol.,2. Pacerone.,3. Theophylline,4. Lovenox.,5. Atrovent.,6. Insulin.,7. Lantus.,8. Zestril.,9. Magnesium oxide.,10. Lopressor.,11. Zegerid.,12. Tylenol as needed.,ALLERGIES:, PENICILLIN.,PAST MEDICAL HISTORY:,1. History of coal miner's disease.,2. History of COPD.,3. History of atrial fibrillation.,4. History of coronary artery disease.,5. History of coronary artery stent placement.,6. History of gastric obstruction.,7. History of prostate cancer.,8. History of chronic diarrhea.,9. History of pernicious anemia.,10. History of radiation proctitis.,11. History of anxiety.,12. History of ureteral stone.,13. History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated. Rapidly moving his upper extremities. No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General: The patient is currently agitated with some level of distress. He has rapid respiratory rate. He is responsive to verbal commands by looking at the eyes.,Vital Signs: As per the monitors are stable.,Extremities: Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas. There is also edema of the forearm extending up to the mid upper arm area. Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect. There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1. Ulceration of bilateral upper extremities.,2. Cellulitis of upper extremities.,3. Lymphedema of upper extremities.,4. Other noninfectious disorders of lymphatic channels.,5. Ventilatory-dependent respiratory failure." }

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

{ "text_length": 3217 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done." }

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

{ "text_length": 1016 }

{ "text": "REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. An ultrasound examination had reportedly been done in the past and the mass is being observed. When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there. The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. She has no weight changes consistent with either hyper or hypothyroidism. There is no family history of thyroid cancer in her family. She has no notable discomfort with this lesion. There have been no skin changes. Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:, Essentially unremarkable. The patient has never been hospitalized in the past for any major illnesses. She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS: ,Currently taking no routine medications. She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. This was done in Tijuana. His mom is from central portion of Mexico. There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY: ,The patient is a junior at Hoover High School. She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL: The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. She was alert and oriented x3 and had an appropriate affect.,HEENT: The head and neck examination is most significant. There is mild amount of facial acne. The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK: There is a slightly visible midline bulge in the region of the thyroid isthmus. A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine. There are some shotty adenopathy in the area. No supraclavicular nodes were noted.,CHEST: Excursions are symmetric with good air entry.,LUNGS: Clear.,CARDIOVASCULAR: Normal. There is no tachycardia or murmur noted.,ABDOMEN: Benign.,EXTREMITIES: Extremities are anatomically correct with full range of motion.,GENITOURINARY: External genitourinary exam was deferred at this time and can be performed later during anesthesia. This is same as too for her rectal examination.,SKIN: There is no acute rash, purpura, or petechiae.,NEUROLOGIC: Normal and no focal deficits. Her voice is strong and clear. There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range. T4 and TSH levels were recorded as normal. Free thyroxine was normal, and the serum pregnancy test was negative. There was no level of thyroglobulin recorded on this. A urinalysis and comprehensive metabolic panel was unremarkable. A chest x-ray was obtained, which I personally reviewed. There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. This will have some impact on the postoperative adjunctive therapy. The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. All of the family's questions have been answered. This is a very anxious and anxiety provoking time in the family. I have made every effort to get the patient under schedule within the next 48 hours to have this operation done. We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy." }

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

{ "text_length": 6601 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:, Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,SPECIMENS:, Urine sent for culture.,ABNORMAL FINDINGS: ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices. Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS: ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction. He has had a STING procedure performed but continues to have reflux bilaterally. Plan is for another injection.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, IV antibiotics were given. He was then placed in a lithotomy position with adequate padding of his arms and legs. His urethra was calibrated to 12-French with a bougie a boule. A 9.5-French cystoscope was used and the offset system was then used. His urethra was normal without valves or strictures. His bladder was fairly normal with minimal trabeculations but no cystitis noted. Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone. This was similarly found on the left side where the Deflux was not close to the orifice as well. It was slightly more difficult because of the amount impacted upon our angle for injection. We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect. Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding. Similar procedure was done on the left. This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed. There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection. At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra. The patient tolerated the procedure well and was in stable condition upon transfer to Recovery. A low-dose of IV Toradol was given at the end of the procedure as well." }

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

{ "text_length": 2910 }

{ "text": "HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly." }

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

{ "text_length": 854 }

{ "text": "CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for \"attention.\" The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she \"tripped\" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL: The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS: Stable.,HEENT: Negative.,NECK: Supple. Carotid upstrokes are 2+.,LUNGS: Clear.,HEART: Normal S1 and S2. No gallops. Rate is regular.,ABDOMEN: Soft. Positive bowel sounds. Nontender.,EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender.,NEUROLOGICAL: Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1. Falls ,2. Anxiety and depression.,3. Hypertension.,4. Hypercholesterolemia.,5. Coronary artery disease.,6. Osteoarthritis.,7. Chronic obstructive pulmonary disease.,8. Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation." }

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

{ "text_length": 2715 }

{ "text": "COSTOCHONDRAL CARTILAGE INJECTION,PROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the supine position.,Intravenous access was established. The patient was given mild narcotics for sedation. For further details, please refer to anesthesia note.,DESCRIPTION OF PROCEDURE:, The area of discomfort was palpated under fluoroscopy and the costochondral cartilages that were symptomatic were marked out. After careful asepsis, local anesthesia was given subcutaneously and a 0.25-gauge hypodermic needle was inserted into the costochondral cartilage junction, taking care not to stray from the rib. Fluoroscopy in AP and lateral positions confirmed good position of the needle in the * costochondral junction and subsequently after aspiration, 0.5 mL of Depo-Medrol 80 and 0.5 mL of 0.5% Marcaine was injected. The same procedure was carried out at the * costochondral junction.,POSTPROCEDURE INSTRUCTIONS:,1. After a period of 30 minutes of observation, during which there was no distress and good relief of symptoms was noted, the patient was discharged home.,2. The patient has been given instructions on watching for possible pneumothorax and any respiratory distress. The patient will call us if any inflammation, swelling, or other associated discomfort arises. We will call the patient in 48 hours." }

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

{ "text_length": 1430 }

{ "text": "SUBJECTIVE:, The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:, She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:, She is a nonsmoker.,REVIEW OF SYSTEMS:, As noted above.,OBJECTIVE:,Vital Signs: Temperature: 98.2. Pulse: 64. Respirations: 16. Blood pressure: 110/56. Weight: 169.,General: Alert and oriented x 3. No acute distress noted.,Neck: No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur or gallops present.,Breasts: Exam performed with a female nurse present. The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal: She did have full range of motion of her shoulders. She did have tenderness upon palpation over the right bicipital tendon. There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING: Most recent hemoglobin A1c was 5.6% back in October 2004. Most recent lipid checks were obtained back in July 2004. We have not had this checked since that time.,ASSESSMENT:,1. Type II diabetes mellitus.,2. Hypertension.,3. Right shoulder pain.,4. Hyperlipidemia.,PLAN:,1. She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2. We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3. I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4. She is going to follow up in the clinic in three months for a complete comprehensive examination. If any questions, concerns or problems arise between now and then she should let us know." }

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

{ "text_length": 3206 }

{ "text": "HISTORY:, This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction. After catheterization, the patient underwent cystoscopy on 4/13. On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved. Final diagnosis was adenocarcinoma of the prostate. Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:, None,PROCEDURES:,Cystoscopy: Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate: 45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue." }

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

{ "text_length": 881 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL: ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. Each half was further subdivided with chopping and removed with phacoemulsification. The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece. The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS. The corneal wounds were hydrated and verified to be water-tight. Antibiotic ointment was placed, followed by a patch and shield. The patient was transported to the PACU in good/stable condition. There were no complications. Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case." }

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

{ "text_length": 2849 }

{ "text": "PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:, The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy. Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day. She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon. The distal ileum was examined, which was normal in appearance. Random biopsies were obtained from the ileum and placed in jar #1. Random biopsies were obtained from the normal-appearing colon and placed in jar #2. Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1. Small internal hemorrhoids.,2. Ileal colonic anastomosis seen in the proximal transverse colon.,3. Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies. If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains." }

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

{ "text_length": 1928 }

{ "text": "CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues. This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort. The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized. One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields). Radiographs are taken, and these fields are marked on the patient's skin. The patient is then transferred to the diagnostic facility and placed on a flat CT scan table. Scans are then performed through the targeted area. The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan. The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures. This volume is then reconstructed in 3-dimensional space. Utilizing the beam's-eye view features, the appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures. Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated." }

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

{ "text_length": 2288 }

{ "text": "REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Mild mitral regurgitation.,3. Mild tricuspid regurgitation." }

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

{ "text_length": 1050 }

{ "text": "PREOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS: ,Zero.,SPECIMENS: ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovium was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry and intact and follow up in my office." }

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

{ "text_length": 3608 }

{ "text": "DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3" }

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

{ "text_length": 4548 }

{ "text": "INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:, Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.,2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL: ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.,2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.,2. Mild hypertensive cardiomyopathy with an EF of 48%.,3. Poor exercise capacity due to cardiovascular deconditioning.,4. Suboptimally controlled blood pressure on today's exam." }

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

{ "text_length": 1470 }

{ "text": "GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Genitalia: Bilaterally descended testes without tenderness or masses. No hernias palpable. Rectal examination revealed normal sphincter tone, no rectal mass. Prostate was *. Stool was Hemoccult negative." }

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

{ "text_length": 1979 }

{ "text": "CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of \"heartburn.\" He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, \"Fleet enema.\" ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable." }

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

{ "text_length": 3314 }

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

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

{ "text_length": 7147 }

{ "text": "DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.,FINDINGS:, Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition." }

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

{ "text_length": 1782 }

{ "text": "P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks \"un poquito\" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a \"stacker.\" He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had \"a little\" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under \"previous occurrence of the same pain\" a notation of \"Yes, but it was not really the same, it was just a little and tolerable.\" There is an additional note on the side which states \"no pain prior to this injury or on that day, occasional (but low back).\" Saw this notation, he says today that he did not state this and that the form was done by \"Edna\" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty \"moving.\" He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has \"good and bad days\" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a \"tightness\" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:, AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.)." }

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

{ "text_length": 10165 }

{ "text": "CHIEF COMPLAINT:, Ankle pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above. Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:" }

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

{ "text_length": 821 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest. There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma. A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included. The predominant portion of the biopsy was of the lesion itself.,Lesion was removed. Attention was turned toward the area. Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture. All counts were correct. The procedure was closed. A sterile dressing was applied. There were no complications. The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.," }

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

{ "text_length": 1057 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:, Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:, General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife. She confirms the history of loud snoring at night with witnessed apnea. The result of the sleep study was reviewed. This showed moderate sleep apnea with significant desaturation. The patient was unable to tolerate treatment with CPAP. At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate. A tortuous appearance of the septum also was observed. This morning, I talked to the patient and his wife about the findings. I reviewed the CT images. He has no history of sinus infections and does not recall a history of nasal trauma. We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway. Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage. I will get the best look at it when he is asleep. We discussed recovery as well. He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,: General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke. Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose. A Crowe-Davis mouth gag was placed. The tonsils were very large and touched the uvula. The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars. Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate. Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present. A very crowded pharynx was appreciated. The tonsils were first removed using electrodissection technique. Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula. The uvula was grasped with the Alice clamp. I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate. We switched over from the Bayonet cautery to the blunt needle tip electrocautery. The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar. This incision was then deepened with the electrocautery on a cutting current. The uvular artery just to the right of the midline was controlled with the suction electrocautery. The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty. A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine. The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures. The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures. A much improved appearance of the oropharynx with a greatly improved airway was appreciated. A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed. I removed the cottonoids from both nostrils. Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left. The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle. A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator. When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator. The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected. This tissue also was sent as a separate specimen to pathology. The intraseptal space was irrigated with saline and suctioned. The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut. I observed no evidence of purulent secretion or polyp formation within the nostrils. The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides. There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose. No packing was used in the nostrils. Polysporin ointment was introduced into both nostrils. The mouth gag was reintroduced and the pack removed from the nasopharynx. The nose and throat were irrigated with saline and suctioned. An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed. Sponge and needle count were reported correct. The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition. He tolerated the operation excellently. Estimated blood loss was about 15-20 cc. In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery." }

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

{ "text_length": 6539 }

{ "text": "REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. The patient reports having worsening emesis and emesis a few times. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1. Diabetes mellitus.,2. Hypertension.,3. Renal failure, on dialysis.,MEDICATIONS:, Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General: The patient denies fever or chills. Pulmonary: The patient denies hemoptysis. Cardiovascular: Refer to HPI. GI: The patient denies hematemesis or melena. The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL: A well-nourished, well-developed male in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils seem to be equal, round, and reactive. Extraocular muscles are full, but the patient has left eye ptosis.,NECK: Supple without JVD or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI is displaced 0.5 cm lateral to the midclavicular line. Regular rate and rhythm, S1, S2. No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN: Positive bowel sounds, nondistended and nontender. No hepatosplenomegaly.,EXTREMITIES: Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction. Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000. PT 11.3, INR 1.1, and PTT 24.1. Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4. CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6. Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1. Paroxysmal atrial fibrillation. The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm. The patient is currently in sinus rhythm.,2. Emesis. The etiology is unclear. The patient reports that the emesis is better. The patient is just having some nausea.,3. Non-Q-wave myocardial infarction. EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4. Diabetes mellitus.,5. Renal failure.,6. Hypertension.,7. Hypercholesterolemia.,PLAN:,1. We will start amiodarone to keep from going back into atrial fibrillation.,2. Echocardiogram.,3. Aspirin and IV heparin.,4. Serial CK-MB and troponin.,5. Cardiac catheterization, possible percutaneous coronary intervention. The risks, benefits, and alternatives were explained to the patient through a translator. The patient understands and wishes to proceed.,6. IV Integrilin." }

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

{ "text_length": 3409 }

{ "text": "SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening. He finished up his Augmentin, by a day or two later he was off the Lortab. Mom has not noticed any unusual voice change. No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce. He has not had any nasal discharge or ever had any bleeding. He seems to be breathing better.,OBJECTIVE:, Exam looks good. The pharynx is well healed. Tongue mobility is normal. Voice sounds clear. Nasal passages reveal no discharge or crusting.,RECOMMENDATION:, I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive. He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth. It is okay to chew gum and it is okay to eat crunchy foods such as potato chips. The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well. There are no other restrictions or limitations. I told Mom, I had written to Dr. XYZ to let her know of the findings. The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed. He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure." }

[ { "label": " Office Notes", "score": 1 } ]

{ "text_length": 1797 }

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

{ "text_length": 5525 }

{ "text": "Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:, The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation.,Past Medical History:, Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.,Past Surgical History:, Appendectomy at age 21. C-Section 8 years ago.,Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.,Social History:, Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.,Family History:, Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases.,Medications:, Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use.,Allergies:, No known drug allergies.,Review of systems:, No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.,Physical Examination:,VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress.,SKIN: No rashes, nodules, ecchymoses, or petechiae.,LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities.,NECK: Supple. No increased jugular venous pressure. No thyromegaly.,CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales.,CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly.,RECTAL: Brown stool. Guaiac negative.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits.,STUDIES:,Chest X-ray (10/03):,Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable.,CT Scan of Chest (10/03):,Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size.,Renal Biopsy:,Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified.,Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin.,Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate." }

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

{ "text_length": 6309 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:, Revision rhinoplasty (CPT 30450). Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture. During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma. The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect. The patient was consented for the above-stated procedure. The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues. In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear. Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb. Betadine was utilized for preparation. A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane. I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested. These were placed aside in saline. Hemostasis was obtained with bipolar electrocauterization. Bovie electrocauterization was also employed as needed. The entire length of the wound was then closed with 5-0 plain running locking suture. The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture. Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose. A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision. The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums. Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum. At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip. The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect. Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome. These were done transmucosally after elevating the tract using a Cottle elevator. Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms. The patient had a series of double-dome sutures placed into the nasal tip. Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing. Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation. A Gore-Tex small implant had been selected, previously incised. This was taken to the back table and carved under sterile conditions. The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum. It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut. The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage. This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis. The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures. The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic. There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum. The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition. He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area. He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest." }

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

{ "text_length": 4995 }

{ "text": "CHIEF COMPLAINT: , \"A lot has been thrown at me.\",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY: ,Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY: ,The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM: ,This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact.,LABORATORY DATA:, A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits.,AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS.,AXIS II: Deferred.,AXIS III: Hypertension, Huntington disease, status post overdose.,AXIS IV: Chronic medical illness.,AXIS V: 30.,PLAN,1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions.,2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3. Substance abuse. No acute concern for alcohol or benzo withdrawal.,4. Psychosocial. Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults." }

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

{ "text_length": 7937 }

{ "text": "OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room. After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray. After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium. After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate. A 45-degree forceps then used to open up the maxillary sinus. There was some prominent tissue and just superior to this, the anterior ethmoid was opened. The 45-degree forceps was then used to open the maxillary sinus ostium. This was enlarged with backbiting rongeur. After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa. After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate. There was noted to have prominence in the anterior ethmoidal area. This was then opened with 45-degree forceps. This mucosa was then removed from the anterior area. The maxillary sinus ostium was then opened with 45-degree forceps. Tissue was removed from this area. This was sent as right maxillary mucosa. After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus. Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally. This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction. After this was completed, a septoplasty was performed. The incision was made with a #15 blade Bard-Parker knife. The flap was then elevated, overlying the spur that was protruding into the right nasal cavity. This was excised with a #15 blade Bard-Parker knife. The tissue was then laid back in position. After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx. , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon. The patient was then awakened and taken to recovery room in good condition." }

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

{ "text_length": 2761 }

{ "text": "EXTERNAL EXAMINATION: , The body is that of a 62-inch, 112-pound white female who appears the recorded age of 41 years. The body is clad in a pink and white gown. Three pillows and a blanket are also received with the body. The scalp is covered in thick brown hair with flecks of gray. The irides are brown. There is bilateral tache noire. The eyelids are yellow and dry. The eyes have a sunken appearance. The ears and nose are normally developed. The mouth has partial natural dentition. The left upper first bicuspid through the molars are absent. The left lower bicuspid is absent. The right upper second molar is capped. The left lower first molar appears decayed. The teeth are otherwise in good repair. The lips and buccal mucosa have no trauma. The neck is unremarkable except for a 2.5 cm tracheostomy scar just above the suprasternal notch. The posterior portion of the neck is unremarkable and free of scars. An obliquely oriented 6 cm surgical scar is on the anterior left chest with an underlying, implanted, medical device. The breasts are pendulous and otherwise unremarkable. There is white powder underneath the breasts. A round, 8 mm scar is on the upper central abdomen. A horizontally oriented 2.5 cm linear scar is on the central upper abdomen. A faint, approximately 1 cm scar is on the right mid lateral abdomen. There are a few striae on the hips and lower abdomen. The external genitalia are normally developed and white powder covers the perineum. The labia are dry. The urethral meatus is visible and 3.5 mm in diameter. No objects or substances are in the vagina other than a slight amount of yellow-white discharge. The anus is patent and unremarkable. Faint, pink-white, flat, 1-2 cm scars are just above the superior portion of the gluteal cleft. A 2.5 cm, somewhat square shaped, brown macule is on the left buttock. There are no open and active decubitus ulcers. The upper extremities have flexion contractures with striae on the medial portions of the upper arms. The muscles of the extremities are atrophic. The lower extremities are partially shaved. The left fifth toe is absent. The skin on the back is intact. The spine has accentuated thoracic kyphosis and lumbar lordosis. The skin demonstrates tenting,RADIOGRAPHS: , Postmortem radiographs show radiopaque shadows extending from the periosteum of the femurs, left tibia, and right ischial tuberosity. Diffuse, severe osteoporosis is present. The 11th thoracic vertebral body has an endplate fracture. Degenerative joint changes are noted in the acromioclavicular joints, hips, right knee, left foot, and pelvis. The left fifth toe is amputated along with the distal portion of the left fifth metatarsal. Radiographs of anterior neck structures and iliac wings are not remarkable. Calculi are seen in the urinary tract. Staples are in the gallbladder bed.,INTERNAL EXAMINATION: , The muscles of the chest and abdominal wall are normally developed. The subcutaneous tissues are dry. The panniculus is 2.5-3 cm. In the left chest wall is an implanted medical device with a wire extending through subcutaneous tissues of the left neck and into the left scalp. A flat, four-prong electrical device is in the subgaleal area of the left scalp. A wire then further extends into the cranial cavity. The peritoneal cavity is unremarkable and dry. There are no intraperitoneal adhesions except for an adhesion of the anterior portion of the stomach to the anterior abdominal wall in the area of the previously described round abdominal scar. The organs are in the usual anatomic relations. The pleural cavities are dry. The lungs are well aerated. The pericardial sac is remarkable for a 1 cm focal area of anterior pericardial adhesion to the anterior portion of the right ventricle. There is some lateral adhesion of the right ventricle to the right lateral portion of the pericardial sac. No other adhesions are noted. The pericardial sac is dry. The diaphragm is intact. The sternum is unremarkable. The ribs have no trauma and are normally developed with somewhat prominent costochondral junctions.,CARDIOVASCULAR SYSTEM: , The pericardial sac is remarkable as previously described. The epicardial fat of the 255 gram heart is otherwise unremarkable. The root of the aorta has no atherosclerosis. The arch and descending aorta have minimal atherosclerosis (see attached CV pathology report).,RESPIRATORY SYSTEM: , The right and left lungs are 260 and 245 grams, respectively. The lungs have a normal number of lobes and have light pink-red outer surfaces. The bronchi are unobstructed. The well-aerated lung parenchyma is pink-red. There are no anthracosis, tumors, cysts, or infarcts. The upper lobe bronchi contain a scant amount pearlescent fluid. The proximal bronchi contain yellow pearlescent fluid. The lower lobe distal bronchi contain some scattered areas of yellow pearlescent fluid. The alveoli otherwise contain foamy, reddish-white fluid. The pulmonary arteries contain no emboli. The lower lobes have firm areas of partial consolidation with yellow-green pearlescent fluid. The firm area of the left lower lobe is ,4 x 4 x 3 cm. The right lung has scattered firm areas (<lcm).,HEMOLYMPHATIC SYSTEM: , The 215 gram spleen is covered in an intact, gray, somewhat wrinkled capsule. There are two hilar accessory spleens (1.4 and 1 cm in diameter). The splenic parenchyma is dark red-maroon and unremarkable. There is no interstitial fibrosis, tumors, cysts or infarcts. No enlarged lymph nodes are noted. The bone marrow of the lumbar vertebral bodies is red and soft.,GENITOURINARY SYSTEM:, The right and left kidneys are 100 and 130 grams, respectively. The right kidney has a central, 2-2.5 cm, obliquely oriented cleft/scar extending from the central renal pelvis to the upper lateral cortex. The brown-tan outer surfaces are otherwise slightly lobular and granular. The pelvis of the right kidney is mildly dilated. A 1 x 0.6 x 0.7 cm, green-brown stone is in the pelvis of the right kidney. The left renal pelvis has an approximately 0.5 x 0.6 x 1 cm, green-brown stone. The corticomedullary ratios are reduced. The pelvic fat is increased. The left ureter contains pearlescent fluid. The urinary bladder contains ,6 cc of brown-yellow fluid. A 3.8 x 1.2 x 1 cm, white-yellow, somewhat crescent shaped stone is within the lumen of the bladder. The uterus is present and has a normal shape. The cervix is normally developed. The cervical os is large (coned) and contains mucoid fluid. There are a few minute nabothian cysts (<2 mm). A 2 cm, spherical leiomyoma is in the posterior portion of the uterine corpus. The endometrial cavity contains 3 to 4 mm thick, tan endometrium. The ovaries are present, firm and otherwise grossly unremarkable. The fallopian tubes are unremarkable except for a few adhesions of the fimbriated ends.,GASTROINTESTINAL SYSTEM:, The stomach contains 60 cc of green-brown fluid without any solid food fragments. The gastric mucosa is flat, congested, and green-gray. The gastric mucosa is congested. No ulcerations are noted. There are a few congested vessels with minute petechiae around the previously healed ostomy site. An 8 mm blood clot is on the gastric mucosa near the healed/healing gastrostomy site. The wall of the stomach is thin (<3mm). No perforations are noted. The esophagus is not remarkable with gray/pink mucosa. The bowel contains progressively formed feces with the rectum containing hard stool. The appendix is present, but is atrophic/small. The bowel has no perforations. An abundant amount of greenish liquid is in the duodenum. No foreign objects are noted.,HEPATOBILIARY SYSTEM:, The outer surface of the 965 gram liver is covered in a transparent intact capsule. There are very few inferior hepatic adhesions associated with an absent gallbladder. Surgical staples are imbedded in the area of the cystic duct. The hepatic parenchyma is brown-green with a slight pattern of congestion. The bile ducts and portal veins appear grossly unremarkable. No fibrosis, cysts or infarcts are noted. A yellow-white, round, 2 mm nodule is in the anterior portion of the right lobe of the liver.,ENDOCRINE SYSTEM: , The adrenals and pancreas are present and grossly unremarkable. The thyroid is mildly atrophic without nodules.,MUSCULOSKELETAL SYSTEM: , The upper and lower extremities are atrophic as previously described. The trunk musculature is atrophic. A 1 x 1.5 x ,1 cm area of induration/calcification extends from the anterior surface of the right femur. The anterior/lateral cortical surface of the distal right femur metaphysis is rough and irregular. The cortical bone of the lumbar and thoracic vertebral bodies is thin and soft. The iliac wings have no trauma or deformity.,NECK: , The strap muscles of the anterior neck have intact musculature with atrophy of the musculature on the right side. The right sternocleidomastoid is moderately atrophic. There are no hemorrhages. The larynx and piriform recesses contain yellow-tan, mucoid fluid. There is yellow-green, mucoid fluid on the base of the tongue and epiglottis. The larynx contains a scant amount of fluid. The thyroid and cricoid cartilages are intact. The hyoid bone is intact. The tongue is atrophic. There is a yellow-green dry crusted material on the surface of the tongue. The posterior pharyngeal musculature appears atrophic. There are no hemorrhages. A healed tracheostomy site is on the anterior trachea. The carotid arteries and jugular veins are not remarkable. The muscles and cervical vertebral bodies of the posterior neck are not remarkable. The spinal cord and column have no trauma. The posterior laminae are soft.,CENTRAL NERVOUS SYSTEM: , See neuropathology report,MICROSCOPIC EXAMINATION: , (Also see neuropathology and cardiovascular pathology reports),LUNGS, LOWER LOBES: Widespread bronchopneumonia. Intraalveolar debris and bacteria.,Intraalveolar foamy macrophages. Congestion. Edema.,UTERUS: Late proliferative endometrium leiomyoma.,ACCESSORY SPLEEN: Not remarkable.,COLON: Autolysis. Melanosis.,URINARY BLADDER: Chronic inflammation.,OVARIES: Corpora albicantia. Follicular cyst.,FALLOPIAN TUBES: Paratubal cyst. Congestion.,VAGINA: Vascular congestion.,ADRENAL GLANDS: Mild congestion.,STOMACH, GASTROSTOMY: Clotted blood.,LIVER: Focal nodular hyperplasia (single focus). Centrilobular congestion with steatosis,KIDNEYS: Tubular necrosis. Mild vascular congestion.,THYROID: Not remarkable.,PANCREAS: Early autolysis. Mild interstitial fibrosis.,EPIGLOTTIS: Focal ulceration with acute inflammation.,LARYNX, RIGHT ARYEPIGLOTTIC FOLD: Not remarkable." }

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

{ "text_length": 10765 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:, Under general anesthesia with an endotracheal tube, the patient was placed in supine position. A mouth gag was inserted and suspended from Mayo stand. Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate. The adenoid area was inspected. The adenoids were small. The left tonsil was grasped with a tonsil tenaculum. The tonsil was removed with the Gold laser. The apposite tonsil was removed in a similar manner. Hemostasis was secured with electrocautery. Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline. The patient tolerated the procedure well and left the operating room in good condition." }

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

{ "text_length": 1045 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA: ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation in OP position. Normal uterus, tubes and ovaries are noted. Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes. Normal uterus, tubes and ovaries were noted.,INDICATIONS: ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery. The patient was admitted and cervix was found to be 1 cm dilated. Pitocin augmentation of labor was started. The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me. At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest. Vaginal exam was done. Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations. At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section. Clock in the operating room is noted to be 2 minutes faster then the time on trace view. The OR delivery time was 19:36. Delivery of this infant was performed in 14 minutes from the onset of the deceleration. Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s. Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt. 2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine. As the incision site was being injected, the anesthesiologist arrived. The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique. The rectus muscles were separated in midline. The peritoneum was bluntly dissected. The bladder blade was inserted. The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction. The infant was subsequently delivered. Immediately following delivery of the infant. The infant was noted to be crying with good tones. The cord was clammed and cut. The infant was subsequently transferred or handed to the nursery nurse. The placenta was delivered manually intact with a three-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic sutures. Hemostasis was visualized. The uterus was returned to the abdomen. The pelvis was copiously irrigated. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was reapproximated with 0 Vicryl suture. The subcutaneous layer was closed with 2-0 plain gut. The skin was closed in the subcuticular stitch using 4-0 Monocryl. Steri-strips were applied. Sponge, laps, and instrument counts were correct. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition." }

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

{ "text_length": 4316 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated. Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle. Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained. Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged. Cineangiograms were obtained of the left coronary system. This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged. Cineangiograms were obtained, and the catheter and sheath were then withdrawn. The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition. No evidence of hematoma formation or active bleeding. ,COMPLICATIONS: , None. ,TOTAL CONTRAST: , 110 cc of Hexabrix. ,TOTAL FLUOROSCOPY TIME: ,1.8 minutes. ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o. Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push." }

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

{ "text_length": 1725 }

{ "text": "HISTORY: ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries. He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital. This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve. A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve. The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung. The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: ,Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.,DIAGNOSES: ,1. Atrioventricular septal defect.,2. Tetralogy of Fallot with the pulmonary atresia.,3. Bilateral superior vena cava. The left cava draining to the coronary sinus.,4. The right aortic arch.,5. Discontinuous pulmonary arteries.,6. Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Repair of tetralogy of Fallot with external conduit.,3. The atrioventricular septal defect repair.,4. Unifocalization of branch pulmonary arteries.,5. Bilateral balloon pulmonary angioplasty and stent implantation.,6. Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES: ,1. Mild-to-moderate proximal branch pulmonary stenosis.,2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.,3. Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X." }

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

{ "text_length": 7760 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the operating room, placed on the table in supine position. General endotracheal anesthesia was obtained in the usual fashion. The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen. The neck was prepped as well. After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl. A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. The condyle was skeletonized so that it could be easily seen. The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. The neck contents to the hyoid were dissected out. The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. The neck contents were removed as a separate specimen. The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis. A large posterior facial vein was identified and likewise clipped for later use. I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made. I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy. For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap. A skin paddle was drawn out next to the umbilicus about 4 x 4 cm. The skin paddle was incised with the Bovie and down to the anterior rectus sheath. Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl. The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction. The vascular pedicle could be seen entering the muscle in usual fashion. The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel. The wound was then packed with saline impregnated sponges. The rectus muscle with attached skin paddle was then transferred into the neck. The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique. Ischemia time was less than 10 minutes. Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well. There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. The wound was irrigated with copious amounts of saline. The eustachian tube was obstructed with bone wax. The muscle was then laid into position with the skin paddle underneath the conchal bowl. I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. The subcutaneous tissues were closed with interrupted 3-0 Vicryl. The skin was closed with skin staples. There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples. The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened. The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well." }

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

{ "text_length": 5967 }

{ "text": "PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water." }

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

{ "text_length": 689 }

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

{ "text_length": 2457 }

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

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

{ "text_length": 2370 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:, Right undescended testicle.,OPERATIONS:,1. Right orchiopexy.,2. Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis. The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. The testis was identified right at the external inguinal ring. The testis was unable to be brought down into the scrotal sac. The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed. Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in the inguinal and scrotal area. After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. The incision came through the subcutaneous tissue and external oblique fascia was identified. The external oblique fascia was opened sharply and was taken all the way down towards the external ring. The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. After dissecting proximally, the testis was identified in the distal end of the inguinal canal. The testis was pulled up. The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. There was very small hernia, which was removed and was tied at the base. PDS suture was used to tie this hernia sac all the way up to the base. There was a Y right at the vas and cord indicating there was enough length into the scrotal sac. The testis was easily brought down into the scrotal sac. One centimeter superior scrotal incision was made and a Dartos pouch was created. The testicle was brought down into the pouch and was placed into the pouch. Careful attention was done to ensure that there was no torsion of the cord. The vas was medial all the way throughout and the cord was lateral all the way throughout. The epididymis was in the posterolateral location. The testicle was pexed using 4-0 Vicryl into the scrotal sac. Skin was closed using 5-0 Monocryl. The external oblique fascia was closed using 2-0 PDS. Attention was drawn to re-create the external inguinal ring. A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia. After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion. Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable. It was smaller than the other side, probably by 50%. There were no palpable testicular masses. Plan was for the patient to follow up with us in about 1 month. The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. No tub bath for 2 months. The patient and family understood all the instructions." }

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

{ "text_length": 3944 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1. Anterior cervical discectomy of C3-C4.,2. Removal of herniated disc and osteophytes.,3. Bilateral C4 nerve root decompression.,4. Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. Grafting of fibular allograft bone for creation of arthrodesis.,6. Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain. Conservative therapy has failed to improve the problem. Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck. Dissection was carried down through the platysmal musculature and the anterior spine was exposed. The medial borders of the longus colli muscles were dissected free from their attachments to the spine. A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space. Castoff self-retaining pins were placed into the body of the C3 and C4. Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed. Quite a bit of overhanging osteophytes were identified and removed. As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs. A high-speed diamond bur was used to slowly drill these spurs away. I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen. The dura was extremely thin and I could see through it in several areas. I removed the bony compression in the foramen and identified soft tissue and veins overlying the root. All of these were not stripped away for fear of tearing this very tissue-paper-thin dura. However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis. As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally. Under distraction the graft was placed and fit well. An x-ray showed good graft placement.,Attention was turned to spinal instrumentation. A Synthes Short Stature plate was used with four 3-mm screws. Holes were drilled with all four screws were placed with pretty good purchase. Next, the locking screws were then applied. An x-ray was obtained which showed good placement of graft, plate, and screws. The upper screws were near the upper endplate of C3. The C3 vertebral body that remained was narrow after drilling off the spurs. Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure. A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied along with a rigid Philadelphia collar. The operation was then 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 and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material." }

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

{ "text_length": 5027 }

{ "text": "HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.,ALLERGIES:, She is allergic to Sulfa.,CURRENT MEDICATIONS:, Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.,Skin: Without rash.,Eyes: PERRLA. Conjunctivae are clear.,Neck: Supple with adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,ASSESSMENT:,1. Postsurgical menopause.,2. Mood swings.,PLAN:, I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well." }

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

{ "text_length": 2456 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:, Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:, General inhalational anesthetic with caudal block.,FLUIDS RECEIVED: ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:, No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. He was then placed in the supine position and sterilely prepped and draped. Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery. Electrocautery was also used for hemostasis. A subdartos pouch was then created with a curved tenotomy scissors. The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments. As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top. We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps. Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction. We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal. Once this was done, we then had adequate length of the testis into the scrotal sac. Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture. The testis was then placed into the scrotum in the proper orientation. The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic. The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision. IV Toradol was given. Both testes were well descended in the scrotum at the end of the procedure." }

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

{ "text_length": 2583 }

{ "text": "BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings. Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized. This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures. The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin. This created a significant crisp, supratarsal fold. The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus. The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking. Then the skin muscle flap was elevated with sharp dissection. The fat was located and using a scissor the three eyelid compartments were opened. Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized. Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed. The suture line was sutured with interrupted 6-0 silk sutures. Once this was done the procedure was finished.,The patient left the OR in satisfactory condition. The patient was given 50 mg of Demerol IM with 25 mg of Phenergan." }

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

{ "text_length": 1853 }

{ "text": "SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1.,CHEST: Examination of the chest is clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOMEN: Benign. Right renal angle is tender. Bowel sounds are positive.,EXTREMITIES: There is no swelling.,NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5. Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000. BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1. Sepsis due to urinary tract infection. Urine culture shows Escherichia coli, resistant to Levaquin. We changed to doripenem.,2. Urinary tract infection, we will treat with doripenem, change Foley catheter,3. Hypotension. Resolved, continue intravenous fluids.,4. Ischemic cardiomyopathy. No evidence of decompensation, we with monitor.,5. Diabetes type 2. Uncontrolled. Continue insulin sliding scale.,6. Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7. History of coronary artery disease. Troponin indeterminate. Cardiologist intends no further workup. Continue medical treatment. Most likely troponin is secondary to impaired clearance." }

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

{ "text_length": 1414 }

{ "text": "SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above. No fevers, no headaches, no shortness of breath currently. No chest pain or tightness. No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. Occasional stress incontinence. No muscle or joint pain. No concerns about her skin. No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married. She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.,HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.,Extremities: Without cyanosis or edema.,Skin: Without abnormalities.,Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.,Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1. Asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. May also need to consider Singulair. She is to call me if she is not improving. If her shortness of breath worsens she is to call me or go into the emergency department. We will plan on following up for reevaluation in one month.,2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the time being.,3. Premenstrual dysphoric disorder. She may have some perimenopausal symptoms. We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. Hematuria. Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. She does have some frequent dysuria but is not having it currently.,5. Cervical dysplasia. Pap smear is taken. We will notify the patient of results. If normal we will go back to yearly Pap smear. She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. Recommend she get 1200 mg of calcium and 400 U of vitamin D a day." }

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

{ "text_length": 4543 }

{ "text": "CHIEF COMPLAINT:, A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient started the last 3-4 days to do poorly. She was more confused, had garbled speech, significantly worse from her baseline. She has also had decreased level of consciousness since yesterday. She has had aphasia which is baseline but her aphasia has gotten significantly worse. She eventually became unresponsive and paramedics were called. Her blood sugar was found to be 40 because of poor p.o. intake. She was given some D50 but that did not improve her mental status, and she was brought to the emergency department. By the time she came to the emergency department, she started having some garbled speech. She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department. When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement. ,REVIEW OF SYSTEMS:,GENERAL: No recent fever, chills. No recent weight loss.,PULMONARY: No cough, chest congestion.,CARDIAC: No chest pain, shortness of breath.,GI: No abdominal pain, nausea, vomiting. No constipation. No bleeding per rectum or melena.,GENITOURINARY: She has had frequent urinary tract infection but does not have any symptoms with it. ENDOCRINE: Unable to assess because of patient's bed-bound status.,MEDICATIONS: ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d. 600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day. The patient had recently reduced that to 24 units. MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg. On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d. 5 mg, Nystatin powder. She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL: She is awake, alert, appears to be comfortable.,VITAL SIGNS: Blood pressure 111/43, pulse 60 per minute, temperature 37.2. Weight is 98 kg. Urine output is so far 1000 mL. Her intake has been fairly similar. Blood sugars are 99 fasting this morning. ,HEENT: Moist mucous membranes. No pallor,NECK: Supple. She has a rash on her neck. ,HEART: Regular rhythm, pacemaker could be palpated.,CHEST: Clear to auscultation.,ABDOMEN: Soft, obese, nontender.,EXTREMITIES: Bilateral lower extremities edema present. She is able to move the left side more efficiently than the right. The power is about 5 x 5 on the left and about 3-4 x 5 on the right. She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8. LFTs normal. She is anemic with a hemoglobin of 9.6, hematocrit 29. INR 1.1, pro time 14. Urine done in the emergency department showed 20 white cells. It was initially cloudy but on the floor it has cleared up. Cultures from the one done today are pending. The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures. There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1. Cerebrovascular accident as evidenced by change in mental status and speech. She seems to have recovered at this point. We will continue Coumadin. The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2. Recurrent urinary tract infection. Will await culture at this time, continue Cipro.,3. Diabetes with episode of hypoglycemia. Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor. At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4. Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5. Hypothyroidism, continue Synthroid.,6. Hyperlipidemia, continue Lipitor.,7. The patient is not to be resuscitated. Further management based on the hospital course." }

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

{ "text_length": 5065 }

{ "text": "REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign. A yolk sac is visualized. What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen. However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm. The left ovary measures 3.3 x 1.9 x 3.5 cm. No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09. A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time. A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion." }

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

{ "text_length": 962 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Refractory priapism.,POSTOPERATIVE DIAGNOSIS:, Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE: ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure. The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:, Informed written consent was obtained. The patient was taken to the operative suite and administered anesthetic. The patient was sterilely prepped and draped in the supine fashion. A #15 French Foley catheter was inserted under sterile conditions. Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length. Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum. The fascia was incised in elliptical fashion for approximately 2 cm. A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested. Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm. Vein was irrigated. One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks. Tunnel was then created from the superior most groin region to the incision in the penile shaft. Saphenous vein was then passed through this tunnel with the aid of a hemostat. Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal. There were no leaks noted. There was good flow noted within the saphenous vein graft. Penis was noted to be in a flaccid state. All incisions were irrigated copiously and closed in several layers. Sterile dressings were applied. The patient was cleaned, transferred to recovery room in stable condition.,PLAN: ,We will continue with antibiotics for pain control, maintain Foley catheter. Further recommendations to follow." }

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

{ "text_length": 2561 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Nasal septal deviation.,2. Bilateral internal nasal valve collapse.,3. Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1. Nasal septal deviation.,2. Bilateral internal nasal valve collapse.,3. Bilateral external nasal valve collapse.,PROCEDURES:,1. Revision septoplasty.,2. Repair of internal nasal valve collapse using auricular cartilage.,3. Repair of bilateral external nasal valve collapse using auricular cartilage.,4. Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor. There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS: ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s. He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine. Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL: ,The patient was taken to the operating room and laid supine upon the OR table. After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally. Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor. The caudal septum appeared to be now in adequate position. There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place. Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side. Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine. Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed. Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures. Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion. Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times. This was very carefully harvested. This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine. Following this, the cartilage was removed. It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity. The spreader grafts were sutured in place using submucoperichondrial pockets. After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery. These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places. Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin. Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture. This was sutured in place using a 5-0 self-absorbing gut suture. The lower lateral cartilage has had some inherent asymmetry. This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support. An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture. Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision. Very carefully, the skin and subcutaneous tissue envelopes were reflected. The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures. The marginal incisions were then closed using 5-0 fast-absorbing gut. Doyle splints were placed and secured down using a nylon suture. They had ointment also placed on them. Following this, nasopharynx was suctioned. There were no further abnormalities noted and everything appeared to be in nice position. Therefore, an external splint was placed after the application of Steri-Strips. The patient tolerated the procedure well. He was awakened in the operating room. He was extubated and taken to the recovery room in stable condition." }

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

{ "text_length": 5880 }

{ "text": "FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications." }

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

{ "text_length": 2504 }

{ "text": "REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath. He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home. His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts. He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems. He feels that he has been in good health until this current episode. His appetite has been good. He denies swelling in his feet or ankles. He denies chest pain. He denies any problems with bowel habits. He denies any unexplained weight loss. He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL: A gentleman seen who appears his stated age.,VITAL SIGNS: Blood pressure is 130/70.,CHEST: Chest expands equally bilaterally. Breath sounds are heard bilaterally.,HEART: Had a regular rhythm, no gallops or rubs.,ABDOMEN: Obese. There is no organomegaly. There are no bruits. There is no peripheral edema. He has good pulse in all 4 extremities. He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5. On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1. Acute renal failure, probable renal vein thrombosis.,2. Hypercoagulable state.,3. Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event. He most likely has a hypercoagulable state and has bilateral pulmonary emboli. Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher. Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered. A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife. Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis. If not and his renal failure progresses, we are looking at dialytic intervention. Both he and his wife were aware of this. ,Thank you very much for asking to see this acutely ill gentleman in consultation with you." }

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

{ "text_length": 3029 }

{ "text": "OBSERVATIONS: , FEV1 is 3.76, 103% predicted. FVC is 4.98, 110% predicted. Ratio is 75. FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%. DLCO is 35, 121% predicted. Residual volume is 3.04, 139% predicted. Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:, Mild restrictive airflow limitation. Clinical correlation is recommended." }

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

{ "text_length": 398 }

{ "text": "CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6\",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem." }

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

{ "text_length": 4896 }

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

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

{ "text_length": 930 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,ANESTHESIA: ,General endotracheal.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Subglottic stenosis down to 5 mm with mature cicatrix.,3. Tracheal granulation tissue growing through the stents at the midway point of the stents.,5. Three metallic stents in place in the proximal trachea.,6. Distance from the true vocal cords to the proximal stent, 2 cm.,7. Distance from the proximal stent to the distal stent, 3.5 cm.,8. Distance from the distal stent to the carina, 8 cm.,9. Distal airway is clear.,PROCEDURES:,1. Rigid bronchoscopy with dilation.,2. Excision of granulation tissue tumor.,3. Application of mitomycin-C.,4. Endobronchial ultrasound.,TECHNIQUE IN DETAIL: ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. She had a Dedo laryngoscope placed. Her airways were inspected thoroughly with findings as described above. She was intermittently ventilated with an endotracheal tube placed through the Dedo scope. Her granulation tissue was biopsied and then removed with a microdebrider. Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes. She tolerated the procedure well, was extubated, and brought to the PACU." }

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

{ "text_length": 1434 }

{ "text": "HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.,PAST MEDICAL HISTORY:, The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:, She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL: The patient is an elderly frail white female in no distress. LUNGS: Clear. HEART: Sounds are regular. ABDOMEN: She has a protuberant abdomen. She has tenderness to palpation in the lumbosacral area. Sciatic notch tenderness is not present. Straight leg raise testing evokes back pain. NEUROLOGICAL: She is awake, alert, and oriented. Speech is intact. Comprehension is normal. Strength is intact in the upper extremities. She has giveaway strength in the lower extremities. Reflexes are diminished at the knees and ankles. Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture. A CT scan has shown some healing of this fracture. She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain. She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments. At this point, I believe the patient is a good candidate for L5 kyphoplasty. I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery. Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. The patient understands the issues involved. She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08." }

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

{ "text_length": 3142 }

{ "text": "OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other. The ear infection itself is not contagious but the respiratory infection preceding it is transmittable. Otitis media is most often seen in infants and young children. There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture. Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,* Irritability.,* Ear pain, fullness, hearing loss.,* Infants may pull on ear.,* Fever.,* Vomiting.,* Discharge from ear.,* Diarrhea.,TREATMENT:,* Diagnosis is by physical exam and otoscopic exam. Sometimes fluid from the ear is cultured.,* Pain relievers, like acetaminophen (Tylenol). Infant pain relievers are available.,* Decongestant to relieve symptoms of upper respiratory tract infection.,* Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin. Finish ALL antibiotics as prescribed. Do not stop the medication even if symptoms subside.,* Avoid swimming until infection goes away.,* Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,* Surgery to remove adenoids if they are enlarged.,* Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache." }

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

{ "text_length": 1896 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. His abdomen was prepped and draped in a standard, sterile surgical fashion. A Foley catheter was placed for bladder decompression. Marcaine was injected into his umbilicus. A small incision was made. A Veress needle was introduced in his abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus. A 5-mm port was then placed just to the right side of the umbilicus. Another 5-mm port was placed just suprapubic in the midline. Upon inspection of the cecum, I was able find an inflamed and indurated appendix. I was able to clear the mesentery at the base of the appendix between the appendix and the cecum. I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix. I put the appendix in an Endocatch bag and removed it through the umbilicus. I irrigated out the abdomen. I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications." }

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

{ "text_length": 1632 }

{ "text": "PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval." }

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

{ "text_length": 1279 }

{ "text": "REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks. She has been using a walker for ambulation due to disabling pain in her left thigh and lower back. She was seen by her primary care physician and was scheduled to go for MRI yesterday. However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall. Since then, she was unable to ambulate. The patient called paramedics and was brought to the emergency room. She denied any history of fall. She reported that she stepped the wrong way causing the pain to become worse. She is complaining of severe pain in her lower extremity and back pain. Denies any tingling or numbness. Denies any neurological symptoms. Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture. Orthopedic consultation was called for further evaluation and management. On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago. She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY: ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son.,PHYSICAL EXAMINATION:,GENERAL: The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL: Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity. Tenderness to palpation is present. Leg rolling is positive for severe pain in the left proximal hip. Further examination of the spine is incomplete secondary to severe leg pain. She is unable to perform a straight leg raising. EHL/EDL 5/5. 2+ pulses are present distally. Calf is soft and nontender. Homans sign is negative. Sensation to light touch is intact.,IMAGING:, AP view of the hip is reviewed. Only 1 limited view is obtained. This is a poor quality x-ray with a lot of soft tissue shadow. This x-ray is significant for basicervical-type femoral neck fracture. Lesser trochanter is intact. This is a high intertrochanteric fracture/basicervical. There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray. We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:, Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient. Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip. At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee. She denies any pain elsewhere. She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture. I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type. Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest. She understands above and is willing to undergo further procedure. The goal and the functional outcome have been explained. Further plan will be discussed with her once we obtain the bone scan and the radiographic studies. We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient. I will continue to follow up." }

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

{ "text_length": 4862 }

{ "text": "CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was \"moderately severely\" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a \"curtain\" came down over both visual fields, like \"everything was in the shade.\" During the episode he felt fully alert and aware of his surroundings. He concurrently heard a \"grating sound\" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly \"normal\" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions." }

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

{ "text_length": 4404 }

{ "text": "CHIEF COMPLAINT:, The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:, She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:, Prenatal vitamins.,ALLERGIES:, She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS: Weight: 124 pounds. Blood pressure 96/54. Pulse: 72. Respirations: 16. LMP: 10/18/03. Age: 39.,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. She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen: Soft. No masses.,Pelvic: Uterus is involuting.,Rectal: She has one external hemorrhoid which has inflamed. Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:, Satisfactory three-week postpartum course, seasonal allergies. We will try Patanol eyedrops and Allegra 60 mg twice a day. She was cautioned about the possibility that this may alter her milk supply. She is to drink extra fluids and call if she has problems with that. We will try ProctoFoam HC. For the hemorrhoids, also increase the fiber in her diet. That prescription was written, as well as one for Allegra and Patanol. She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon. She will call and return if she continues to have problems with allergies. Meantime, rechecking in three weeks for her final six-week postpartum checkup." }

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

{ "text_length": 2625 }