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{ "text": "REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.,IMPRESSION:,1. Concentric hypertrophy of the left ventricle with left ventricular function.,2. Moderate mitral regurgitation.,3. Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area." }

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

{ "text_length": 1370 }

{ "text": "XYZ, S.,RE: ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth, now failed, is scheduled for removal. As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant. I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period. If you have any additional suggestions or concerns, please give me a call.,Best regards,," }

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

{ "text_length": 1105 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the emergency department revealed both-bone forearm fracture. Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction. After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was induced with propofol for conscious sedation via the emergency department staff. After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture. Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier. The patient was aroused from anesthesia and tolerated the procedure well. Post-reduction plain films revealed some anterior displacement of the distal fragment. At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement. We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.," }

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

{ "text_length": 1554 }

{ "text": "CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus." }

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

{ "text_length": 1398 }

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

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

{ "text_length": 3591 }

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

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

{ "text_length": 2956 }

{ "text": "REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen. No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas. No pancreatic ductal dilatation is seen. There is no abnormal adjacent stranding. No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber. There is no evidence for obstruction. The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable. There is a 4.2 cm cystic lesion of the right adnexal region. No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1. A 2.2 cm low attenuation lesion is seen at the pancreatic tail. This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised. Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed. Alternatively, an MRI may be obtained.,2. Cholelithiasis.,3. Left basilar atelectasis.,4. A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised." }

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

{ "text_length": 1629 }

{ "text": "PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication." }

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

{ "text_length": 2908 }

{ "text": "S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally. The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot. She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter. This is a central plug. She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter. This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1. Bilateral bunions.," }

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

{ "text_length": 924 }

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

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

{ "text_length": 635 }

{ "text": "TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY: ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. This list was inclusive, but not exclusive. An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS: ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room. After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table. Lumbar spine was shaved, prepped, and draped in the usual sterile fashion. An incision was carried out from L4 to S1. Hemostasis was obtained with bipolar and Bovie cauterization. A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum. At this time, laminectomy was carried out of L5-S1. Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. At this time, the disk was entered with a #15 blade and bipolar. The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic. At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound. There were no complications." }

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

{ "text_length": 2694 }

{ "text": "CHIEF COMPLAINT:, Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,CHRONIC/INACTIVE CONDITIONS,1. Hypertension.,2. Hyperlipidemia.,3. Glucose intolerance.,4. Chronic obstructive pulmonary disease?,5. Tobacco abuse.,6. History of anal fistula.,ILLNESSES:, See above.,PREVIOUS OPERATIONS: , Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,PREVIOUS INJURIES: , He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest.,ALLERGIES: , TO BACTRIM, SIMVASTATIN, AND CIPRO.,CURRENT MEDICATIONS,1. Lisinopril.,2. Metoprolol.,3. Vitamin B12.,4. Baby aspirin.,5. Gemfibrozil.,6. Felodipine.,7. Levitra.,8. Pravastatin.,FAMILY HISTORY: , Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke.,SOCIAL HISTORY: ,The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Denies weight loss/gain, fever or chills.,ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.,RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum.,GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. The patient is well developed, well nourished, and with fair attention to grooming. The patient is moderately overweight.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATION: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs. There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click, or rub. Carotid pulses 2+ without bruits. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 2+ bilaterally, without audible bruits. Extremities show no edema or varicosities." }

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

{ "text_length": 3888 }

{ "text": "CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration." }

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

{ "text_length": 3395 }

{ "text": "DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture." }

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

{ "text_length": 801 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1. Injection for myelogram.,2. Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:, Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:, Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient. ,PROCEDURE DETAIL: ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03. After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table. All of his bony prominences were well-padded. At this time, a myelogram was then performed. After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram. The needle was localized to the level of L3-L4 region. Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle. At this time, approximately 10 cc of Conray injected into the thecal sac. The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast. The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left. There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy. At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy. A long spinal needle was then inserted into region of surgery on the right. The surgery was going to be on the left. Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region. At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia. At this time, a Weitlaner was inserted. Bovie cautery was used to obtain hemostasis. We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina. A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side. At this time, a Taylor retractor was then inserted and held there for retraction. Suction as well as Bovie cautery was used to obtain hemostasis. At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression. Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots. Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive. We removed the extruded disc with further freeing up of the S1 nerve root. A nerve root retractor was then placed. Identification of disc space was then performed. A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade. A small pituitary was then inserted within the disc space and more disc material was freed and removed. The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc. Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound. We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur. At this time, a small piece of Gelfoam was then used to cover the exposed nerve root. We did not have any dural leaks during this case. #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin. Sterile dressings were then applied. The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition. At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level." }

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

{ "text_length": 5425 }

{ "text": "GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred.," }

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

{ "text_length": 1494 }

{ "text": "REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation." }

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

{ "text_length": 3029 }

{ "text": "HISTORY:, This is an initial visit for this 95-year-old gentleman with a Hospice diagnosis of CHF. He was referred to us by Dr. ABC, who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20-25%. The patient was seen in the office approximately three days ago with a clinical diagnosis of bronchitis. The FES, as well as the daughter report that he has had significant clinical and functional decline over the last two to three weeks. He is no longer ambulatory. His appetite is significantly decreased and he had significant unmeasured weight loss. He is notably more weak. He is unable to perform any of the activities of daily living and he is increasingly somnolent with poor sleep at night. The patient says that he is ready to die, that he is after all 95 years old and is aware that his clinical and functional status has been declining. He worked as a chef for almost seven decades and retired approximately two years ago. He denies pain. He admits to some cough, but he believes the cough is improved on the current antibiotic. He does note that he sleeps poorly and unable to indicate a cause for that difficulty in sleeping. He reports that he recently made a trip to California where he said goodbye to his children that live there. The patient reports that his goals of care are to stay at home. He has never been hospitalized with the exception of some surgery on his back in Houston, Texas decades ago that he has no interest in going to a hospital and that he would be happy to sign a DNR form and that he would like no heroics performed in the event that his heart or breathing stops. He denies anxiety or depression and feels that his life has been quite full and quite successful and that when time comes, he is ready to go.,MEDICATIONS:, His medications include Avelox 400 mg. He is on day four of a seven-day dose. He is on Coreg 3.125 mg a day, lisinopril 5 mg a day, Coumadin 2.5 mg a day, digoxin 0.125 mg every other day, Lasix 80 mg twice daily, Inspra twice daily, and he is on a transdermal nitro patch 12 hours on and 12 hours off. He takes Tylenol extra strength every four to six hours for bilateral shoulder pain typically one to two doses a day.,PHYSICAL EXAMINATION: , Exam reveals a cachectic somnolent gentleman, who appears to be comfortable. His blood pressure is 90/60. His heart rate is 80 and irregular. His respiratory rate is 14. Head reveals marked temporal wasting. He is anicteric. The pupils are equal and round. There is jugular venous distention noted approximately 2-3 cm above the notch. Chest shows good air entry bilaterally with scattered rhonchi. No audible wheezing. His heart sounds are irregular and there is a musical systolic ejection murmur radiating to the axilla. The abdomen is soft with a large midline well-healed surgical scar. The bowel sounds are normoactive. There is no tenderness or palpable organomegaly. He has 2+ edema of his lower extremities with some weeping of the right lower extremity and no evidence of infection. Neurologically, while somnolent easily aroused and speech is quite clear. He identities the date as October of 2008, but is otherwise oriented. His short-term memory is quite poor. His insight is also poor. He appears to be somewhat sad. There are mild regular tremors, right hand worse than left, but there is otherwise no focal neurological deficit.,A phone conversation with his daughter, Xyz, his health care proxy, ensued. His daughter is very concerned with his clinical decline and is raising the question of whether he would benefit from hospitalization. She reports that her mother died after a many-year course with heart failure and had upwards of three dozen hospitalizations. At each hospitalization, she seem to derive benefit and wondered if her dad would drive equal benefit from hospitalizations. She is aware that he is unwilling to be hospitalized and I believe hopefully that the Hospice team might persuade him. She also reports that he has been talking about dying for nearly five years.,ASSESSMENT:, A 95-year-old gentleman with endstage CHF with recent significant clinical and functional decline. The patient appears to have relatively little in the way of symptoms, although perhaps some sleep hygiene might be of help. While today the patient appears to be very calm and sedated, the history is one of significant emotional lability. Family is having great difficulty accepting the terminality of the patient's circumstances.,PLAN:, A DNR was placed in the house after the above-noted conversation was had. I believe the patient might benefit from low-dose hypnotic and 7.5 mg of Restoril was ordered. Reassessment of the patient's condition is warranted. A family meeting will be offered to review the circumstances of the patient's condition in hopes that family might better accept his wishes and to develop a plan of care for this gentleman." }

[ { "label": " Hospice - Palliative Care", "score": 1 } ]

{ "text_length": 4976 }

{ "text": "PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES PERFORMED:,1. Lateral escharotomy of right upper arm burn eschar.,2. Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:, Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:, After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure." }

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

{ "text_length": 2509 }

{ "text": "DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,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 COMPLAINT: ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was \"slammed from behind\" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be \"okay to walk.\" He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that \"these things can take a long time.\" He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS: ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that \"I can power through it.\" \"I have learned how to manage the pain, using exercise, stretching, and diversion techniques.\" It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW: ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as \"unknown.\" The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as \"no acute bony process.\" Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of \"a little compression of what appears to be T7 and T8 on the lateral view.\" Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that \"the patient's symptoms are so mild as to almost not warrant intervention.\" He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study." }

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

{ "text_length": 18425 }

{ "text": "PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications." }

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

{ "text_length": 7079 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes. He was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. X. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by the endoscopist. It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. X. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal." }

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

{ "text_length": 1801 }

{ "text": "REASON FOR CONSULTATION:, Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. This apparently was positive in two separate locations within the suspicious area. She also underwent MRI, which suggested that there was significant size to the area involved. Her contralateral left breast appeared to be uninvolved. She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications. She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight. Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps. There are no any significant scars on the right breast as she has only undergone needle biopsy at this point. Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:, A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction. I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim. A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy. I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration. I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure. We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant. In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery. Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed. In any case, she does prefer this option in order to avoid the need for an implant. We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction. At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy. For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days. We may cancel this if the chance of postoperative irradiation is high. If this is the case, I think we can do a better job on the reconstruction if we defer it. The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist." }

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

{ "text_length": 4143 }

{ "text": "EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above." }

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

{ "text_length": 2049 }

{ "text": "REASON FOR VISIT: ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has left nursing home facility. He states that his pain is well controlled. He has been working with physical therapy two to three times a week. He has had no drainage or fever. He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed. He has no effusion noted. His range of motion is 10 to 105 degrees. He has no pain or crepitance. On examination of his right foot, he is nontender to palpation of the metatarsal heads. He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex. He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation. Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures. These appear to be extraarticular. They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT: ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy. He may be weightbearing as tolerated on his right side. I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion. I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias. He said he has had the left thigh for a number of years and has been followed by a neurologist for this. He states that he has had some right-sided paresthesias now for a number of weeks. He claims he has no other symptoms of any worsening stenosis. I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot." }

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

{ "text_length": 2705 }

{ "text": "PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:, Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:, No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case." }

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

{ "text_length": 2126 }

{ "text": "DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge." }

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

{ "text_length": 1559 }

{ "text": "CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and \"complete resection\" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal." }

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

{ "text_length": 2215 }

{ "text": "SUBJECTIVE:, The patient is well-known to me. He comes in today for a comprehensive evaluation. Really, again he borders on health crises with high blood pressure, diabetes, and obesity. He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc. He knows better and has been through some diabetes training. In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004. Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days. He has had elevated blood pressure. His other concerns include allergic symptoms. He has had irritable bowel syndrome with some cramping. He has had some rectal bleeding in recent days. Also once he wakes up he has significant difficulty in getting back to sleep. He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:, As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:, Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:, Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions: None.,PHYSICAL EXAMINATION:,VITAL SIGNS: As above.,GENERAL: The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear.,NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit.,CHEST: No chest wall tenderness or breast enlargement.,HEART: Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS: Clear to auscultation and percussion.,ABDOMEN: Significantly obese without any discernible organomegaly. GU: Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL: Smooth, nonenlarged prostate with just some irritation around the rectum itself. No hemorrhoids are noted.,EXTREMITIES: Some slow healing over the tibia. Without clubbing, cyanosis, or edema. Peripheral pulses within normal limits.,NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits.,SKIN: Noted to be normal. No subcutaneous masses noted.,LYMPH SYSTEM: No lymphadenopathy noted.,BACK: He has pain in his back in general.,ASSESSMENT/PLAN:,1. Diabetes and hypertension, both under less than appropriate control. In fact, we discussed increasing the Lantus. He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control. He knows what needs to be done with the absence of carbohydrates, and especially simple sugar. He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile. I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range. He has allergic rhinitis for which Zyrtec can be used.,2. He has irritable bowel syndrome. We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened. For the bleeding I would like to obtain a sigmoidoscopy. It is bright red blood.,3. For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene. I will look forward to seeing him back in a month. I will call him with the results of his lab. His medications were made out. We will use some Elocon cream for his seborrheic dermatitis of the face. Zyrtec and Flonase for his allergic rhinitis." }

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

{ "text_length": 4084 }

{ "text": "CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:, This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. He is now sleeping in an upright position. He was sent for CAT scan originally of his chest. The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. He was subsequently was sent for a dedicated abdominal CAT scan and MRI. The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. He was referred to us for further assessment. He denies any significant abdominal pain, any nausea or vomiting. His appetite is fine. He has had no significant changes in his bowel habits or any rectal bleeding or melena. He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps. He does have a history of frequent urination. Has been followed by urologist for this. There is no family history of pancreatic cancer. There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:, Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:, Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:, He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister.,SOCIAL HISTORY:, He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL: Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.,HEART: There is distant heart sounds.,ABDOMEN: Obese. It is soft. It is nontender. Examination was done as relatively sitting up as the patient was unable to recline. Bowel sounds are present. There is no obvious mass or organomegaly.,GENITALIA: Deferred.,RECTAL: Deferred.,EXTREMITIES: Revealed about 1+ pitting edema. Bilateral peripheral pulses are intact.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION:, Both left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy. We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention. Prior to that the patient will undergo an esophagogastroduodenoscopy." }

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

{ "text_length": 4277 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:, None.,FINDINGS:, Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:, The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion. This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube. The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:, The patient was given additional fentanyl, Versed as well as paralytics for the procedure. Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina. There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. Extensive secretions extended down into the secondary airways. This was lavaged with saline and suctioned dry. There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator. Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2. The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture." }

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

{ "text_length": 1892 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not gotten worse recently and there is no numbness in her toes. She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. GENERAL: She is a middle-aged white female, not in any distress. HEENT: No lymphadenopathy or mucositis. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: No focal deficits noted. PELVIC: Normal-appearing external genitalia. Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. No local or distant metastasis. Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy. She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1. Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2. The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3. The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4. The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.," }

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

{ "text_length": 2433 }

{ "text": "LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis." }

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

{ "text_length": 515 }

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

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

{ "text_length": 847 }

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

{ "text_length": 2288 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:, Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:, The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased. Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening. A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma. The patient had a metastatic workup, which was negative including a brain MRI and bone scan. The bone scan showed only signal positivity in the left 9th rib near the tumor. The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia. He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. The patient was intubated with a double-lumen endotracheal tube. Intravenous antibiotics were given. A Foley catheter was placed. The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion. An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass. The skin and subcutaneous tissues were dissected sharply with the electrocautery. Good hemostasis was obtained. The tumor was easily palpable and clearly involving the 8th to 9th rib. A thoracotomy was initially made above the mass in approximately the 7th intercostal space. Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection. The thoracotomy was extended anteriorly and posteriorly. It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected. The ribs of the chest wall were first cut at their anterior aspect. The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery. Hemostasis was obtained with both electrocautery and clips. The chest wall segment to be resected was retracted laterally and posteriorly. It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement. Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor. The spleen and the stomach were identified and were protected. Inferiorly, the resection of the chest wall was continued in the 10th interspace. The dissection was then carried posteriorly to the level of the spine. The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung. A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection. Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies. The ribs were disarticulated, closed to or at their articulations with the spine. Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery. There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section. The specimen was oriented for the pathologist who came to the room. Hemostasis was obtained. The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures. This produced a satisfactory diaphragmatic repair without undue tension. A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly. This was secured with a #1 silk suture. The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect. A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually. The resulting mesh closure was snug and deemed adequate. The serratus muscle was reapproximated with figure-of-8 0 Vicryl. The latissimus was reapproximated with a two #1 Vicryl placed in running fashion. Of note, two #10 JP drains were placed over the mesh repair of the chest wall. The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl. The wounds were dressed. The patient was brought from the operating room directly to the North ICU, intubated in stable condition. All counts were correct.," }

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

{ "text_length": 5387 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.," }

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

{ "text_length": 1779 }

{ "text": "PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1. Wound debridement x2, including skin, subcutaneous, and muscle.,2. Insertion of tissue expander to the medial wound.,3. Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA: ,General.,INDICATIONS: , This patient developed a compartment syndrome. She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg. She was doing very well and was obviously improving.,The swelling was reduced. A compartment pressure had obviously improved based on examination. She was therefore indicated for placement of tissue expander for ventral wound closure. The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well. Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood them well. All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:, The patient was placed on the operating table and general anesthesia was achieved. The medial wound was noted to be approximately 10.5 cm in length x 4 cm. The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width. Both wounds were then thoroughly debrided. The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion. This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides. At this point adequate debridement was performed and healthy tissue did appear to be present. Initially on the medial wound I did place the DermaClose RC continuous external tissue expander. On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately. I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor. I then did place adequate tension on the sutures. Continued tension will be noted after engaging the tension controller. At this point I performed the similar procedure to the lateral wound. The skin anchors were placed separately and appropriately on either side of the skin margin. The line loop from the tension controller was placed in lace like manner through the skin anchors. The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained. Adequate tension was placed in this region. A non thick dressing was then applied to the open-wound region and sterile dressing was then applied. No complications were encountered throughout the procedure and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition." }

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

{ "text_length": 3591 }

{ "text": "REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:, Reviewed as above and otherwise unchanged.,FAMILY HISTORY:, Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS: ,1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3. Fluconazole 37.5 mg daily.,4. Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES: ,1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3. Immunosuppression.,4. Mucosal candidiasis.,5. Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:, None.,PLANS: ,1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.,2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above." }

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

{ "text_length": 5221 }

{ "text": "TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The central pulmonary arteries are patent with no evidence of embolus. There is no significant mediastinal, hilar, or axillary lymphadenopathy. The trachea and mainstem bronchi are patent. The esophagus is normal in course and caliber. The lungs are clear with no infiltrates, effusions, or masses. There is no pneumothorax. Scans through the upper abdomen are unremarkable. The osseous structures in the chest are intact. ,IMPRESSION: , No acute abnormalities." }

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

{ "text_length": 782 }

{ "text": "HISTORY OF PRESENT ILLNESS:, A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. There was also a question of liver metastases at that time.,OPERATION PERFORMED:, Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe." }

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

{ "text_length": 1130 }

{ "text": "SUBJECTIVE:, The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.,PAST MEDICAL HISTORY:, She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition.,MEDICATION:, Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs: Blood pressure is 124/72. Temperature 99.2. Respirations 20 unlabored. Weight: 137 pounds.,HEENT: Normocephalic. Conjunctivae noninjected. No mattering noted. Her TMs are bilaterally clear, nonerythematous. Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck: Supple. Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory: Clear. No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular: Regular rate and rhythm. S1 and S2 normal, no murmur.,Abdomen: Soft. No organomegaly. She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable. She has no suprapubic tenderness.,Extremities: She has good range of motion of upper and lower extremities. Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria. Culture and sensitivity is pending. Her Strep test is negative. Culture is pending.,ASSESSMENT:,1. Urinary dysuria.,2. Left flank pain.,3. Pharyngitis.,PLAN:, A 1 g of Rocephin IM was given. Call Dr. B's office tomorrow morning incase a second IM dose is needed. If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug. Push fluids. Await strep culture report. Follow up with Dr. XYZ if no better or symptoms worsen." }

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

{ "text_length": 2482 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic. He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus. The left shoulder and upper extremities were then prepped and draped in the usual manner. A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus. This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery. Hemostasis was achieved with the cautery. The deltoid fascia were identified, skin flaps were then created. The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein. The deltoid was then retracted. There was marked hematoma and swelling within the subdeltoid bursa. This area was removed with rongeurs. The biceps tendon was identified which was the landmark for the rotator interval. Mayo scissors was utilized to split the remaining portion of the rotator interval. The greater tuberosity portion with the rotator cuff was identified. Excess bone was removed from the greater tuberosity side to allow for closure later. The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well. Both of these were tagged with Ethibond sutures for later. The humeral head was delivered out of the wound. It was localized to the area of the anteroinferior glenoid region. The glenoid was then inspected, and noted to be intact. The fracture was at the level of the surgical neck on the proximal humerus. The canal was repaired with the broaches. An #8 stem was chosen as it was going to be cemented into place. The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion. Trial reduction was performed. The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder. At this point, the wound was copiously irrigated with gentamycin solution. The canal was copiously irrigated as well and suctioned dry. Methyl methacrylate cement was mixed. The cement gun was filled and the canal was filled with the cement. The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured. Excess cement was removed by sharp dissection. Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later. Once the cement was cured, the modular head was impacted on to the Morse taper. It was stable and the shoulder was reduced. The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant. The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well. The rotator interval was closed with #2 fiber wire in an interrupted fashion. The biceps tendon was ________ within this closure. The wound was copiously irrigated with gentamycin solution, suctioned dry. The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture. Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples. Subcutaneous tissues were infiltrated with 0.25% Marcaine solution. A bulky dressing was applied to the wound followed by application of a large arm sling. Circulatory status was intact in the extremity at the completion of the case. The patient was then transferred to recovery room in apparent satisfactory condition." }

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

{ "text_length": 4251 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg. He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe. Since that time, he has had difficulty pushing off when he walks. He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness. He has chronic mild back pain, but this has been persistent for many years and has not changed. He has experienced cramps in both calves for the past year. This dissipated about two months ago. He does not think that his left leg is weak. He does not have any bowel or bladder incontinence. There is no radicular pain. He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October. He then saw you a couple of months later. He has undergone an EMG and nerve conduction studies. Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant. He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia. He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me. He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it. Once it was started, it increased to about 800 and then came down to about 500 when it was stopped. He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s. I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this. More recently, he has been started taking Zetia. He does not have any proximal weakness. He denies any myalgias., ,PAST MEDICAL HISTORY:, He has coronary artery disease and has received five stents. He has hypertension and hypercholesterolemia. He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test. He believes that his glucose shot up to over 300 with this testing. He does not take any medications for this and his blood glucoses are generally normal when he checks it. He has had plastic surgery on his face from an orbital injury. He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix. , ,ALLERGIES:, He has no known drug allergies., ,SOCIAL HISTORY:, He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up., ,FAMILY HISTORY:, His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus. He has difficulty sleeping. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:" }

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

{ "text_length": 4239 }

{ "text": "PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:, The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:, I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:, The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.," }

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

{ "text_length": 7793 }

{ "text": "HISTORY:, A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION: ,1. Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2. History of fibromyalgia.,3. History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4. History of chronic fatigue.,5. History of hypothyroidism.,6. History of depression.,7. History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation. The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested. The patient will follow up after RAST allergy testing for further treatment recommendations. At this point, no changes in her medication were prescribed until her followup visit." }

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

{ "text_length": 1112 }

{ "text": "CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden \"pressure-like\" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and \"went to sleep.\" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was \"normal.\" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine." }

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

{ "text_length": 2844 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well." }

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

{ "text_length": 3988 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position. The right foot was prepared and draped in usual sterile manner. Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg. At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. At this time, attention was directed to the first inner space using sharp and blunt dissection. Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. At this time, the lateral release was stressed and was found to be complete. The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm. The screw was placed following proper technique. The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. The packing of the cancellous bone was held in place with bone wax. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily. The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. The tourniquet was dropped and color and temperature of all digits returned to normal. The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.," }

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

{ "text_length": 5966 }

{ "text": "ADMITTING DIAGNOSES,1. Acute gastroenteritis.,2. Nausea.,3. Vomiting.,4. Diarrhea.,5. Gastrointestinal bleed.,6. Dehydration.,DISCHARGE DIAGNOSES,1. Acute gastroenteritis, resolved.,2. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time. This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse. The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count. Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs. The patient's nausea, vomiting, and diarrhea did resolve during his hospital course. Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well. The patient also denied any abdominal pain upon day of discharge. The patient was also started on prednisone as per GI recommendations. He was started on 60 mg p.o. Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home. He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair. We will also start him on a tapered dose of prednisone for 4 weeks. We will start him on 15 mg p.o. for seven days. Then, week #2, we will start him on 40 mg for 1 week. Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop. He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations." }

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

{ "text_length": 2457 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1. Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2. Left mandibular vestibular abscess.,PROCEDURE,1. Extraction of teeth #2. #5, #12, #15, #18, #19, #31.,2. Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS: , None.,DRAIN:, Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:, The patient was taken to the PACU in stable condition.,INDICATION:, Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:, Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine. The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated. This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab. An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19. The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained. Penrose drain was then placed using a curved hemostat. The drain was secured with 3-0 silk suture. The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully. After completion of the procedure, the throat pack was removed, the pharynx was suctioned. The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube. The nasogastric tube was then removed. Patient was then extubated and taken to the PACU in stable condition." }

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

{ "text_length": 2713 }

{ "text": "CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of \"drop\" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice." }

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

{ "text_length": 2351 }

{ "text": "EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. This most likely will affect the S1 nerve root on the left. There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. There is mild neural foraminal stenosis present. Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. There is facet sclerosis bilaterally. Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present. There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present. There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy. Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease." }

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

{ "text_length": 2835 }

{ "text": "TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula. She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein. She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P. She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T. She lives with her husband and she also has a son at home and she is a very active lady. She is right handed. The plan was to place an AV fistula at the left wrist. The risks and benefits were fully explained to her. She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically. Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist. The cephalic vein was exposed. The superficial branch of the radial artery was carefully protected and the radial artery was exposed. There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture. There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery. There were no complications." }

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

{ "text_length": 1653 }

{ "text": "CHIEF COMPLAINT:, Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS: ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:, As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL: No acute distress at the time of exam.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair.,NECK: Trachea is at the midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm.,ABDOMEN: Bowel sounds are heard throughout. Soft and nontender.,EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema.,MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2. Postoperative anemia, Feosol 325 mg one q.d.,3. Pain management. Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain. Additionally, she will utilize ice to help decrease edema.,4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5. Osteoarthritis, Celebrex 200 mg b.i.d.,6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day.,8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT." }

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

{ "text_length": 4626 }

{ "text": "OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well." }

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

{ "text_length": 968 }

{ "text": "S: , The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:, Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.,MEDICATIONS:, Refer to chart.,O: , The patient presents in wheelchair, verbal and alert. Vascular: He has absent pedal pulses bilaterally. Trophic changes include absent hair growth and dystrophic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings include temperature change and edema +2. Nails: Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1. Dystrophic nails.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,4. Diabetes.,P: ,Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided. The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails." }

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

{ "text_length": 1079 }

{ "text": "DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction. His bowel function started to improve. He was on TPN prior to coming to Hospital. He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some. The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine. At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia. This has been treated successfully with Zyvox and Levaquin and Diflucan. He seems to be currently doing much better. He is only using BiPAP in the evening. As stated above, he is eating better. He had some evidence of redness and exquisite swelling around his genital and lower abdominal region. This may be mainly dependent edema versus anasarca. The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. This morning, the patient denies any acute distress. He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:, He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily. The patient is going to require physical therapy to help with assistance in strength training. He is also going to need respiratory care to work with his BiPAP. His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%. The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS: On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL: A well-developed white male who appears in no apparent distress.,HEENT: Unremarkable.,CARDIOVASCULAR: Positive S1, S2 without murmur, rubs, or gallops.,LUNGS: Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN: Positive for bowel sounds. Soft, nondistended. He does have some generalized redness around his abdominal region and groin. This does appear improved compared to presentation last week. The swelling in this area also appears improved.,EXTREMITIES: Show no clubbing or cyanosis. He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC: The patient is alert and oriented to person and place. He is alert and aware of surroundings. We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL: The patient moves all extremities without difficulty. He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following: White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4. Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN: ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning. Hopefully, long-term planning will be discharge home. He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time." }

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

{ "text_length": 4262 }

{ "text": "PROCEDURE:, Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1. Acute cholecystitis.,2. Status post laparoscopic cholecystectomy.,3. End-stage renal disease on hemodialysis.,4. Hyperlipidemia.,5. Hypertension.,6. Congestive heart failure.,7. Skin lymphoma 5 years ago.,8. Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family. The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85. EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm. There is sludge in the gallbladder wall versus a stone in the gallbladder wall. Thickening of the gallbladder wall with positive Murphy sign. She has a history of cholecystitis. Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal. So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered. The patient also had history of CHF in the past and recently had some workup done. The patient does not remember initially. Surgical consult also requested and blood culture and urine culture also ordered. The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy. The patient also seen by nephrologist and underwent dialysis. The patient's white count went down 6.1, afebrile. On postop day #1, the patient started eating and also walking. The patient also had chronic bronchitis. The patient was later on feeling fine, discussed with surgery. The patient was then able to discharge to home and follow with the surgeon in about 3-5 days. Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o. 2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days. The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient. Discharged home." }

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

{ "text_length": 3136 }

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

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

{ "text_length": 5015 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: ,Gallbladder.,BRIEF HISTORY: ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture. The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department. Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure. The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain. During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder. The patient did well postdrainage. The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp. However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003. A HIDA scan had been performed, which showed no cystic duct obstruction. A tube cholecystogram was performed, which showed no cystic or common duct obstruction. There was abnormal appearance of the gallbladder, however, the pathway was patent. Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy. Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS: ,The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered . The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created. The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition." }

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

{ "text_length": 4688 }

{ "text": "ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable." }

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

{ "text_length": 5680 }

{ "text": "DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted through the emergency room. He was admitted to the Intensive Care Unit. He was rewarmed and had blood, sputum, and urine cultures done. He was placed on IV Rocephin. His usual medications of Dilantin and Depakene were given. The patient's hypertension was treated with fluid boluses. The patient was empirically placed on Synthroid and hydrocortisone by Dr. X. Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins. H&H was stable at 33.3/10.9 and platelets of 80,000. White blood cell counts were normal, differential was normal. TSH was 3.41. Free T4 was 0.9. Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement. A cortisol level was obtained prior to administration of hydrocortisone. This was 10.9 and that was not a fasting level. Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef. The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday. The patient was started back on his tube feeds. He tolerated these poorly with residuals. Reglan was increased to 10 mg q.6 h. and erythromycin is being added. The patient's temperature has been stable in the 94 to 95 range. Other vital signs have been stable. His urine output has been diminished. An external jugular line was placed in the Intensive Care Unit. The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there. As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him. He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque. His prognosis is poor." }

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

{ "text_length": 2231 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital. The following sizes of NexGen system were utilized: E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live. Medial compartment had minor changes present. There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides. There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department. Thigh tourniquet was placed upon the patient's right leg. She was prepped and draped in the usual sterile manner. The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time. A straight incision was carried down through the skin and subcutaneous tissue. Hemostasis was controlled with electrocoagulation. Medial parapatellar arthrotomy was created and the knee cap was everted. The ligaments were balanced. A portion of the fat pad was removed and the ACL was completely removed. Drill hole was made in the distal femur. The size to an E, right. Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side. This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made. Intramedullary guide was then placed, pegged, and anterior cut carried out. There was excellent resection. It was flat. Distal cutting guide was then placed in five degrees of valgus. Appropriate cuts were carried out. The standard cut was utilized.,The finishing guide for E was held with pins as well as screws. Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made. The cutting guide was then removed. The bone was removed. Excess bone was taken out posteriorly. The posterior capsule was loosened up. There were two different fabellas in the posterolateral compartment and they were loosened. Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner. An extramedullary tibial cutting guide was then placed, pinned, and held. A cut was carried out parallel to the foot. Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges. Trial range of motion was satisfactory. It was necessary to perform a lateral retinacular release to the patella. The patella was isolated. Approximately 10 mm to 11 mm were reamed off. The size to 32 mm button and drill hole guide was placed, impacted, and drilled. Trial range of motion was satisfactory. The tibial guide was then pinned. Drill hole was placed, broached, and utilized. Copious irrigation was carried out. Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella. The implants were sequentially placed in tibia to femur to patella. Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed. There was excellent ligament balancing. A separate portal was utilized for subcutaneous drain. Tourniquet was deflated and hemostasis was controlled with electrocoagulation. Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were pink and warm with brawny pulses distally at the end of the case. The patient was then transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair." }

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

{ "text_length": 4844 }

{ "text": "REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had \"nervous breakdowns\" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation." }

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

{ "text_length": 3786 }

{ "text": "CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic. The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed. The capsulorrhexis was then performed in a standard circular tear fashion. The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag. The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic. The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization. The lens was noted to center well. The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution. The eye was then checked and found to be watertight; therefore, no suture was used. The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition." }

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

{ "text_length": 1433 }

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

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

{ "text_length": 3962 }

{ "text": "DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. With Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea. A stab incision was made at 2 o'clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day." }

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

{ "text_length": 2369 }

{ "text": "SUBJECTIVE:, The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General: The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs: Blood pressure: 122/70. Temperature: 98.6.,HEENT: Head: Normocephalic. Ears: TMs intact. Eyes: Pupils round, and equal. Nose: Mucosa normal. Throat: Mucosa normal.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft and obese.,Extremities: A lot of fluid in both legs, but especially the left leg is really swollen. At least 2+ pedal edema. The right leg just has a trace of edema. She has pain in her low back with range of motion. She has a lot of pain in her left shoulder with range of motion. It is hard for her to get her hand behind her back. She cannot get it up behind her head. She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1. Multiple problems including left leg swelling.,2. History of leukocytosis.,3. Joint pain involving the left shoulder, probably impingement syndrome.,4. Low back pain, chronic with obesity.,5. Obesity.,6. Frequency with urination.,7. Tobacco abuse.,PLAN:,1. I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel. We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2. Elevate her leg as much as possible and wear support hose if possible. Keep her foot up during the day. We will see her back in two weeks. We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain. If her shoulder pain is not any better, we probably should refer her on over to orthopedist. We did do x-rays of her shoulder today that did not show anything remarkable. See her in two weeks or p.r.n." }

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

{ "text_length": 3755 }

{ "text": "EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis." }

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

{ "text_length": 678 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General. The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle. The risks, benefits, and alternatives of the proposed procedure were discussed with the patient. Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS: ,The patient did receive Ancef antibiotics prior to the procedure. He was then wheeled to the operative suite where a general anesthetic was administered. He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure. Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region. The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery. The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors. This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord. With this accomplished, the testis was then identified. It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord. Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens. Weitlaner retractor was placed to provide further exposure. There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl. Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis. Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment. This was taken down to approximately the two-thirds length of the left scrotal compartment. Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision. A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment. Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors. A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision. A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord. With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis. The sutures were then tied creating the orchiopexy. The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures. Once again hemostasis was maintained with Bovie electrocautery. Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures. External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad. Once this was created, the created ring was inspected and there was adequate room for the cord. There appeared to be no evidence of compression. Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion. The patient had been injected with bupivacaine prior to closing the skin. Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum. He will follow up with Dr. X in 10 to 14 days. Appointment will be made." }

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

{ "text_length": 4890 }

{ "text": "DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:, A 16-month-old with history of penile swelling for 4 days. The patient was transferred for higher level of care. This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent. Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions. This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area. The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics. The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT: Denies any runny nose. ,EYES: No apparent discharge. ,FEEDING: Good feeding. ,CARDIOVASCULAR: There is no cyanosis or edema. ,RESPIRATORY: Denies any cough or wheezing. ,GI: Positive for constipation, no bowel movements for 2 days. ,GU: Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling. ,NEUROLOGIC: Denies any lethargy or seizure. ,MUSCULOSKELETAL: No pain or swelling. ,SKIN: Erythema and edema in the pubic area for the last 3 days. All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin. The transfer labs are as follows: 15.7 for WBC, H&H 12.0 and 36. One blood culture. We will follow the results. He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied. ,PAST SURGICAL HISTORY:, The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations. He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:, He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke. There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature max at ER is 102, heart rate 153.,GENERAL: This patient is alert, arousable, big boy.,HEENT: Head: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Mucous membranes are moist.,NECK: Supple.,CHEST: Clear to auscultation bilaterally. Good air exchange.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Full range of movement. No deformities." }

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

{ "text_length": 2684 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS: ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:, The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis. The patient was in early stage of gestation. Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg. First, under fluoroscopy the fracture was reduced. A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction. A 2-cm radial incision, superficial radial nerve was exposed and protected. Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius. The guidewire was inserted under fluoroscopy. A cannulated drill was used to drill antral hole. Antral awl was inserted. Then we reamed the canal to size 2. Size 2 Micronail was inserted to the medullary canal. Using distal locking guide, three locking screws were inserted distally. The second dorsal incision was made. The deep radial dorsal surface was exposed. Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius. Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius. At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers. Sterile dressing applied. The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days. We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises." }

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

{ "text_length": 2359 }

{ "text": "PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition." }

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

{ "text_length": 5262 }

{ "text": "EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine." }

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

{ "text_length": 882 }

{ "text": "CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1. Inguinal hernia on the left.,2. Baker's cyst.,3. Colon cancer removal.,4. Bilateral knee scopes.,5. Right groin hernia.,6. Low back surgery for spinal stenosis.,7. Status post colon cancer second surgery.,MEDICATIONS:,1. Ambien 12.5 mg nightly.,2. Methadone 10 mg b.i.d.,3. Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN: ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS: ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol. Chewed until 2003.,RECREATIONAL PURSUITS: ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1. Cancer.,2. Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE: A pleasant, cooperative 57-year-old white male.,VITAL SIGNS: Height 5' 9\", weight 167. Blood pressure 148/86. Pulse 78 per minute and regular.,HEENT: Unremarkable. Extraocular movements are full. Cranial nerves II-XII intact.,NECK: Supple.,CHEST: Clear.,CARDIOVASCULAR: Regular rhythm. Normal S1 and 2.,ABDOMEN: No organomegaly. No tenderness. Normal bowel sounds.,NEUROLOGIC: Intact.,MUSCULOSKELETAL: Left knee reveals a range of -10 degrees extension, 126 flexion. His extensor mechanism is intact. There is mild varus. He has good stability at 30 degrees of flexion. Lachman's and posterior drawer are negative. He has good muscle turgor. Dorsalis pedis pulse 2+.,DIAGNOSTICS: ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1. Bilateral knee degenerative joint disease.,2. Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d." }

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

{ "text_length": 2931 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days. ,PAST MEDICAL HISTORY: ,Parkinson disease.,MEDICATIONS:, Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:" }

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

{ "text_length": 1166 }

{ "text": "Pap smear in November 2006 showed atypical squamous cells of undetermined significance. She has a history of an abnormal Pap smear. At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia. She underwent a cone biopsy that per her report was negative for any pathology. She had no vulvar treatment at that time. Since that time, she has had normal Pap smears. She denies abnormal vaginal bleeding, discharge, or pain. She uses Yaz for birth control. She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis. She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections. She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B. She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX: ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use. He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:, She is a public relations consultant. She is a nonsmoker, drinks infrequent alcohol and does not use drugs. She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches. Weight: 139 lb. BMI: 22.4. Blood Pressure: 102/58. GENERAL: She is well-developed and well-nourished with normal habitus and no deformities. She is alert and oriented to time, place, and person and her mood and affect is normal. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. BREASTS: Deferred. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Normal external female genitalia. Vulva, vagina, and urethra, within normal limits. Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance. GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid. This shows an entirely normal transformation zone, so no biopsies are taken. An endocervical curettage is then performed with Cytobrush and curette and sent to pathology. Colposcopy of the vulva is then performed again with acetic acid. There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter. There are absolutely no abnormal vessels within this area. The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV. We will check the results of the ECC. She will return in two weeks for test results. If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes." }

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

{ "text_length": 3386 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:, Aqueductal stenosis.,TITLE OF PROCEDURE: ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:, Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION: ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION: ,Triventricular hydrocephalus most consistent with aqueductal stenosis. The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral. The right frontal area was shaven and then the head was prepped and draped in a standard routine manner. The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine. A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture. Two Weitlaner were used to hold the scalp open. A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated. Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated. CSF was collected for routine studies. We saw the total absence of __________ consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle. I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening. The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________ various motions. We went through the membrane of Liliequist. We could see the basilar artery and the clivus, and there was no significant bleeding from the edges. The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture. The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips. The patient tolerated the procedure well." }

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

{ "text_length": 2505 }

{ "text": "PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:, Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE: ,Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diameter. Purulent material was drained and irrigated with copious amounts of saline flush. A Penrose drain was placed. Penrose drain was ultimately sutured forming a circular drain. The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. Anesthesia, general endotracheal anesthesia. Estimated blood loss approximately 5 mL. Intravenous fluids 100 mL. Tissue collected. Purulent material from buttock abscess sent for usual cultures and chemistries. Culture and sensitivity Gram stain. A single Penrose drain was placed and left in the patient. Dr. X attending surgeon was present throughout the entire procedure." }

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

{ "text_length": 988 }

{ "text": "PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion. A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory. A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly. This was then carefully checked for symmetry and appeared to be satisfactory. All marks were then completed and lightly incised on both breasts. The right breast was approached first. The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery. After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately. This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle. There was very little bleeding with this procedure. After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus. Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket. After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast. Hemostasis was obtained with electrocautery. After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps. On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified. This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology. After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues. The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner. After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area. After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left. Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated. The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached. The nipple was sutured with running intradermal 4-0 Monocryl. Vascularity appeared good throughout. After this had been completed, all wounds were cleaned and Steri-Stripped. The patient tolerated the procedure well. All counts were correct. Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition." }

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

{ "text_length": 3829 }

{ "text": "CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up." }

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

{ "text_length": 1658 }

{ "text": "REASON FOR CONSULTATION:, New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain. Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened. Eventually this prompted him to present to the emergency room. A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease. At that point, he was transferred to XYZ Hospital for further evaluation. On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes. The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum. This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery. There was an abnormal lymph node noted in the AP window and left hilar region. There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm. There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease. There were areas of atelectasis particularly in the right base. There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing. There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax. In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor. All other structures appeared normal. On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed. Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma. At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite. He has not ever had a chronic smoker's cough and still does not have a cough. He has no sputum production or hemoptysis. He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain. He does take a multivitamin on occasion.,SOCIAL HISTORY: He has about a 30-pack-a-year history of smoking. He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked. Since that time he has worked with printing press. He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications. He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL: He has lost about 20 pounds of weight as described above. He also has a trouble with fatigue. No lightheadedness or dizziness. HEENT: He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year. He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain. RESPIRATORY: He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest. No cough, congestion, wheezing, hemoptysis, and sputum production. CVS: He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities. GI: He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools. He has been somewhat constipated recently. GU: He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems. MUSCULOSKELETAL: He denies any new bony aches or pains including back pain, hip pain, and rib pain. No muscle aches, no joint swelling, and no history of gout. SKIN: No rashes, no bruising, petechia, non-healing wounds, or ulcerations. He has had no nail or hair changes. HEM: He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps. ENDOCRINE: He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors. NEURO: He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS: His T-max is 98.8. His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL: No acute distress, pleasant gentleman who appears stated age.,HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without erythema, exudate, or discharge.,NECK: Supple. Nontender. No elevated JVP. No carotid bruits. No thyromegaly. No thyroid nodules. Carotids are 2+ and symmetric.,BACK: Spine is straight. No spinal tenderness. No CVA tenderness. No presacral edema.,CHEST: Clear to auscultation and percussion bilaterally. No wheezes, rales, or rhonchi. Normal symmetric chest wall expansion with inspiration.,CVS: Regular rate and rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly. No guarding or rebound. No masses. Normoactive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. No joint swelling. Full range of motion.,SKIN: No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC: Cranial nerves II through XII are intact. He has intact sensation to light touch throughout. He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes. He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000. The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils. Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7. His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:, MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter. There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. His wife particularly had a very hard time with this prognosis. They preferred not to know the exact average as to how long someone lives with this disease. I did offer chemotherapy as a way to treat this disease. Chemotherapy has been associated both with palliation of symptoms as well as prolong survival. At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal. I would likely use carboplatin and gemcitabine. This would be both medications given on day 1 with a dose of gemcitabine on day 8. This cycle will be repeated after 1-week break so that the cycle lasts 21 days. The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging. A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain. He will be ready to be discharged from the hospital once his pain is under better control. As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday. At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult." }

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

{ "text_length": 9825 }

{ "text": "REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically." }

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

{ "text_length": 4856 }

{ "text": "CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures." }

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

{ "text_length": 6436 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood." }

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

{ "text_length": 3689 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1. CPT code 63075: Anterior cervical discectomy and osteophytectomy, C5-C6.,2. CPT code 63076: Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3. CPT code 22851: Application of prosthetic interbody fusion device, C5-C6.,4. CPT code 22851-59: Application of prosthetic interbody fusion device, C6-C7, additional level.,5. CPT code 22554-51: Anterior cervical interbody arthrodesis, C5-C6.,6. CPT code 22585: Anterior cervical interbody arthrodesis, C6-C7, additional level.,7. CPT code 22845: Anterior cervical instrumentation, C5-C7.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area. The patient was transported to the operative suite and on to the operative table in the supine position. General endotracheal anesthesia was induced. The head was placed on a well-padded head holder. The eyes and face were protected from pressure. A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis. The arms were tucked and draped to the sides. All bony prominences were well padded. An x-ray was taken to confirm the correct level of the skin incision. The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery. The superficial and deep layers of the deep cervical fascia were divided. The midline structures were reflected to the right side. Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected. The carotid sheath was palpated and protected laterally. An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection. Hemostasis was obtained using the electrocautery. The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally. At C5-C6, the anterior longitudinal ligament was divided transversely. Straight pituitary rongeurs and a curette were used to remove the contents of the disc space. All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6. The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints. The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur. Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs. The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies. Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete. A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression. Both nerve roots were visualized and noted to be free of encroachment. The same procedure was then carried out at C6-C7 with similar findings. The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling. The disc spaces were then measured to the nearest millimeter. Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone. The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space. The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis. The grafts were impacted into the disc spaces. There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7. A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position. Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling. An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis. The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6. Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures. The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal. The wound was irrigated with irrigant solution containing antibiotics. The wound was inspected and judged to be dry. The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips. The sponge and needle count were correct. A sterile dressing was applied to the wound. The neck was placed in a cervical orthosis. The patient tolerated the procedure and was transferred to the recovery room in stable condition." }

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

{ "text_length": 6817 }

{ "text": "ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark and smelly. She said she felt okay. She got up. She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out. She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools. She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued. She came to place her call, etc. She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday. She denies any nausea except for when she got weak. She denies any vomiting or any other symptoms.,ALLERGIES: ,She has no known drug allergies.,CURRENT MEDICATIONS:,1. Lipitor, dose unknown.,2. Paxil, dose unknown.,3. Lasix, dose unknown.,4. Toprol, dose unknown.,5. Diphenhydramine p.r.n.,6. Ibuprofen p.r.n.,7. Daypro p.r.n.,PAST MEDICAL HISTORY:,1. Non-insulin diabetes mellitus.,2. History of congestive heart failure.,3. History of hypertension.,4. Depression.,5. Arthritis. She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6. Hyperlipidemia.,7. Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:, She is a nonsmoker. She occasionally has a drink every few weeks. She is divorced. She has 2 sons. She is houseparent at Southern University.,REVIEW OF SYSTEMS: ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE: ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS: Currently was stable. She is afebrile.,GENERAL: She is alert, pleasant in no acute distress. She does complain of some dizziness when she stands up.,HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Sclerae clear. Oropharynx is clear.,NECK: Supple. Full range of motion.,CARDIOVASCULAR: She is slightly tachycardic but otherwise normal.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended. She has no hepatomegaly.,EXTREMITIES: No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:, Her initial chem panel was within normal limits. Her PT and PTT were normal. Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6. She is currently administered transfusion. Platelet count was 125. Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7. PT and PTT were normal. Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1. Gastrointestinal bleed." }

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

{ "text_length": 3498 }

{ "text": "FAMILY HISTORY: , His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY: ,He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:, Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day. Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it. Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY: ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01.,PAST SURGICAL HISTORY:, In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal: He is right-handed. Respiratory: For shortness of breath. Urinary: For frequent urination. GI: He denies any bowel or bladder dysfunction. Genital: He denies any loss of sensation or erectile problems. HEENT: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Cardiac: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall. Current weight is 204 pounds, weight one year ago was 212. BP is 130/66. Pulse is 78. On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, poor dentition. Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. Peripheral vascular, no cyanosis, clubbing, or edema is noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Station and gait are appropriate. He ambulates well without any difficulties or assistance. No antalgic or spastic gait is noted. Examination of the low back reveals no paralumbar spasms. He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature. Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left. Strength is 5/5 and equal bilateral lower extremities. He is able to ambulate on his toes and his heels without any weakness noted. He has negative straight leg raising bilaterally.,FINDINGS:, The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout. At L4-L5 and L5-S1 he has severe disc space narrowing. At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing. At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis. At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1. Do nothing.,2. Conservative therapies.,3. Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed. We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam. I did phone the patient's primary care doctor, Dr. O. Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O. I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG. A copy was provided to the patient and the patient was referred back to his primary care physician for workup. He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed. If he should have any further questions, concerns, or complications, he will contact our office immediately. Otherwise, we will see him p.r.n. Warning signs and symptoms were gone over with him. Case was reviewed and discussed with Dr. L." }

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

{ "text_length": 5617 }

{ "text": "CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics. She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago. She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty. ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints. ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction. HCTZ 25 mg p.o. q.o.d., Oral calcium supplements. In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history. ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative. She moves with great difficulty because of fatigue and malaise. Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22. HEENT: Normocephalic. No scalp lesions. Dry eyes with conjuctival injections. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosion of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. Tonsils not enlarged. No visible exudate. She has difficulty opening her mouth because of pain. SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown. She has some fissuring in the buttocks crease. PULMONARY: Clear to percussion in auscultation. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Protuberant no organomegaly and positive bowel sounds. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis. She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+. I feel no pulse distally in either leg. ,PROBLEMS: ,1. Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2. Rheumatoid Arthritis class 3, stage 4.,3. Flare of arthritis after discontinuing methotrexate.,4. Osteoporosis with compression fracture.,5. Mild dehydration.,6. Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations. We will obtain a dermatology consult. IV leucovorin will be started, and the patient will be put on high-dose corticosteroids." }

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

{ "text_length": 3185 }

{ "text": "CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a \"flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found \"passed out\" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66. HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer." }

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

{ "text_length": 3509 }

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

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

{ "text_length": 8545 }

{ "text": "CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1. Astelin nasal spray.,2. Evista 60 mg daily.,3. Lopressor 25 mg daily.,4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:, The patient underwent right foot surgery and C-section.,FAMILY HISTORY:, The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks. ,ALLERGIES:, THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:, Otherwise negative. ,PHYSICAL EXAMINATION: , ,GENERAL: Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.,NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.,CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. ,CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.,ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.,EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO: Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:," }

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

{ "text_length": 2921 }

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

{ "text_length": 5967 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:, Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus. She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table. The face was prepped with pHisoHex draped. The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology. The report was \"basal cell carcinoma with all margins free of tumor.\" Hemostasis was controlled with the Bovie. Excised lesion diameter was 1.2 cm. The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin. The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin. Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment. The patient was returned to the recovery room in satisfactory condition. She tolerated the procedure satisfactorily, and then no complications. Blood loss was essentially nil." }

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

{ "text_length": 1838 }

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

{ "text_length": 1050 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle. The patient states he has been having fever and chills for the last few days. The patient felt weak and felt unwell. The patient with these complaints came to the emergency room. The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe. No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1. Status post splenectomy.,2. History of marginal B-cell lymphoma.,3. History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,HEENT: Has slight headache.,CARDIOVASCULAR: No history of hypertension, MI, etc.,RESPIRATORY: No history of cough, asthma, TB, shortness of breath.,GI: Unremarkable.,GU: As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE: Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT: No conjunctival pallor or icterus.,NECK: No adenopathy. No carotid bruits.,LUNGS: Clear.,HEART: No gallop or murmur.,ABDOMEN:" }

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

{ "text_length": 1522 }

{ "text": "TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula. She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein. She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P. She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T. She lives with her husband and she also has a son at home and she is a very active lady. She is right handed. The plan was to place an AV fistula at the left wrist. The risks and benefits were fully explained to her. She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically. Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist. The cephalic vein was exposed. The superficial branch of the radial artery was carefully protected and the radial artery was exposed. There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture. There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery. There were no complications." }

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

{ "text_length": 1653 }

{ "text": "SUBJECTIVE:, This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seems to be always like that. 2. On her right great toe, she has got some redness and erythema. Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:, Otherwise reviewed and noted.,CURRENT MEDICATIONS:, None.,ALLERGIES TO MEDICINES:, None.,FAMILY SOCIAL HISTORY:, Everyone else is healthy at home.,REVIEW OF SYSTEMS:, She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General: Well-developed female, in no acute distress, afebrile.,HEENT: Sclerae and conjunctivae clear. Extraocular muscles intact. TMs clear. Nares patent. A little bit of swelling of the turbinates on the left. Oropharynx is essentially clear. Mucous membranes are moist.,Neck: No lymphadenopathy.,Chest: Clear.,Abdomen: Positive bowel sounds and soft.,Dermatologic: She has got redness along the lateral portion of her right great toe, but no bleeding or oozing. Some dryness of her skin. Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1. History of congestion, possibly enlarged adenoids, or just her anatomy.,2. Ingrown toenail, but slowly resolving on its own.,PLAN:,1. For the congestion, we will have ENT evaluate. Appointment has been made with Dr. XYZ for in a couple of days.,2. I told her just Neosporin for her toe, letting the toenail grow out longer. Call if there are problems." }

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

{ "text_length": 1856 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:, Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA: ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:, 10 mL.,FLUIDS:, 1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition. Breathing spontaneously.,INDICATION FOR PROCEDURE: ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible. Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table. As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion. After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx. Peridex mouth rinse was used to prep the oral cavity. This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus. A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier. Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces. Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture. The throat pack was removed. The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition." }

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

{ "text_length": 2768 }