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{ "text": "DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended." }

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

{ "text_length": 995 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This is a 41-year-old registered nurse (R.N.). She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January, her husband of five years seemed to be quite withdrawn. It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman. The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him. They had moved to ABCD where he had recently been employed as a restaurant manager. She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her. She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue. Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder. In January, she went on citalopram. She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ. She describes the family as being somewhat dysfunctional. Father was a truckdriver. She is an only child. She reports that she had a history of anorexia and bulimia as a teenager. In her 20s, she served six years in Naval Reserve. She was previously married for four years. She described that as an abusive relationship. She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION: ,GENERAL: This is an alert and cooperative woman.,VITAL SIGNS: Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC: She makes good eye contact. Speech is normal in rate, volume, grammar, and vocabulary. There is no thought disorder. She denies being suicidal. Her affect is appropriate for material being discussed. She has a sense of future, wants to get back to work, has plans to return to counseling. She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome. She has been off her Mirapex. I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety. She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8. In 1998, she had a normal MRI. Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES: ,1. Seasonal depressive disorder.,2. Restless legs syndrome.,3. Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants. I, therefore, recommend she stay off antidepressants at present. If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation. She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide." }

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

{ "text_length": 4043 }

{ "text": "TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer. The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease. Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer. Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed. The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others. The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL: ,After identifying the patient, the patient was placed supine on the operating room table. The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube. The eyes were protected with Tegaderm. The patient was rotated to 180 degrees towards the operating surgeon. The Foley catheter was placed into the bladder with good return of urine. Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately. A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip. The incision then was planned around the old scar to be excised. A 1% lidocaine with 1 to 100,000 epinephrine was injected. A shoulder roll was applied. The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly. Attention was then turned to performing the level 1 dissection on the left. Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible. The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve. Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric. The submandibular gland was appreciated and retracted laterally. The mylohyoid muscle appreciated. The lingual nerve was appreciated and the submandibular ganglion was ligated. The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis. The marginal mandibular nerve stimulated at the completion of this portion of the procedure. Attention was then turned to incising the fascia along the clavicle on the left side. Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified. The brachial plexus and phrenic nerve were identified. The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels. Attention was then turned to the central neck. The strap muscles were appreciated in the midline. There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature. A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed. Attention was then turned to identify the carotid artery and the internal jugular vein on the left side. This was traced inferiorly, internal jugular vein to the brachiocephalic vein. Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass. Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis. Attention was then turned to the right neck dissection. A posterior flap on the right was raised to the anterior border of the trapezius. The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly. Attention was then turned to identifying the submandibular gland. A digastric tunnel was performed back to the sternocleidomastoid muscle. The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated. The omohyoid muscle was retracted inferiorly. Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle. Subsequently the internal jugular vein was identified. The external jugular vein ligated about 1 cm above the clavicle. Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex. Dissection along the floor of the neck then was performed to allow for mobilization. The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass. Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated. The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly. The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base. The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein. The wound was copiously irrigated. Valsalva maneuver was given. No bleeding points identified. The wound was then prepared for closure. Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon. The wound was closed with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil. The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition." }

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

{ "text_length": 6847 }

{ "text": "REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1. Dilated cardiomyopathy.,2. Ejection fraction less than 10%.,3. Ventricular tachycardia.,4. Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of biventricular automatic implantable cardioverter defibrillator.,2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3. Coronary sinus venogram for left ventricular lead placement.,4. Defibrillation threshold testing x2.,FLUOROSCOPY TIME: ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Vancomycin 1 g (the patient was allergic to penicillin).,2. Versed 10 mg.,3. Fentanyl 100 mcg.,4. Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:, Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.,2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.,3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1. A pacing DDD 60 to 120.,2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.,CONCLUSIONS,1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2. Defibrillation threshold of less than or equal to 17.5 joules.,2. No acute complications.,PLAN,1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Device interrogation in the morning.,4. Completion of the course of antibiotics." }

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

{ "text_length": 7146 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well." }

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

{ "text_length": 5116 }

{ "text": "PROCEDURE PERFORMED:,1. Right femoral artery access.,2. Selective right and left coronary angiogram.,3. Left heart catheterization.,4. Left ventriculogram.,INDICATIONS FOR PROCEDURE:, A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath. The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%. This was a sharp decline from a previous LVEF of 50% to 55%. We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state. The right groin was prepped and draped in the usual sterile manner. 2% Lidocaine was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery. 6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram. A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11. There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1. The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2. The left main coronary artery is free of any disease.,3. The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches. The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4. The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches. One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5. The left anterior descending artery has a patent stent in the proximal LAD. The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss. There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery. The diagonal branches are free of any disease.,6. The right coronary artery is a dominant vessel and has mild luminal irregularities. Its midsegment has a focal area of 30% narrowing as well. The rest of the right coronary artery is free of any disease.,7. The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy. Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram. The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia." }

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

{ "text_length": 3153 }

{ "text": "DESCRIPTION OF OPERATION:, The patient was brought to the operating room and appropriately identified. Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants. Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the pre-placed sutures. An 8-0 nylon suture was then pre-placed for later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants. The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed. There was moderately severe vitreous hemorrhage, which was removed. Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades. These were dissected with curved scissors and judicious use of the vitrectomy cutter. There was some bleeding from the inferotemporal frond. This was managed by raising the intraocular pressure and using intraocular cautery. The surgical view became cloudy and the corneal epithelium was removed with a beaver blade. This improved the view. There is an area suspicious for retinal break near where the severe traction was inferotemporally. The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment. The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen. There was some residual hemorrhagic vitreous skirt seen. The soft-tip cannula was then used to perform an air-fluid exchange. Additional laser was placed around the suspicious area inferotemporally. The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut. A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye. The lid speculum was removed. Maxitrol ointment was instilled over the eye and the eye was patched. The patient was brought to the recovery room in stable condition." }

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

{ "text_length": 2976 }

{ "text": "TITLE OF OPERATION:, Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: , The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life. I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes. I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. We went to the operating room at that time and we did a very large right-sided hemicraniectomy. The patient was put in the intensive care unit. We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room. She was already intubated and under general anesthesia. The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder. The patient tolerated this well. We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. We connected this. Prior to this, we brought in all surgical instrumentation under sterile and standard conditions. We opened the skin as in opening a book and then we also did a myocutaneous flap. We brought in the muscle with it. We had a very good exposure of the skull. We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. All this was irrigated thoroughly. Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. We had absolutely good hemostasis. We put a piece of Gelfoam over the brain. We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely. Once we had done this, irrigated thoroughly once again the skin. We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. The EBL was about 200 cubic centimeters. Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. No complications. The patient went back to the intensive care unit." }

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

{ "text_length": 4918 }

{ "text": "PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture." }

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

{ "text_length": 4999 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed." }

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

{ "text_length": 5377 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. This includes risk of bleeding, infection, scarring, need for further procedure, etc. The patient did sign the informed consent form regarding the Perlane and Restylane. She is aware of the potential risk of bruising. The patient has had Cosmederm in the past and had had a minimal response with this. Please note Lasercaine had to be applied 30 minutes prior to the procedure. The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold. We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold. They were carefully massaged into good position at the end of the procedure. She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site. She has a resting line of the mid glabella that did not respond with previous Botox injection. Once this was filled, the Restylane was massaged into the proper tissue plane. Cold compressors were applied afterwards. She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. Post Restylane and Perlane precautions have been reviewed with the patient as well." }

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

{ "text_length": 1822 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1. Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: ,Approximately 1000 cc.,CELL SAVER RETURNED: ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain. He had previous lumbar laminectomy at L4-L5. He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable. He is suffering from neurogenic claudication. He was unresponsive to extensive conservative treatment. He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia. He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded. His lumbar spine was then sterilely prepped and draped in the usual fashion. A previous midline incision was extended from approximate level of L3 to S1. This was in the midline. Skin and subcutaneous tissue were debrided sharply. Electrocautery provided hemostasis. ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia. The lumbar fascia was identified and split in the midline. Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1. Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4. Once this was completed, a self-retaining retractor was then placed. With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable. These were readily mobile with digital palpation. A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1. This bone was morcellized and placed on the back table for utilization for bone grafting. The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1. Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained. Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1. The microscope was utilized during this portion of procedure for visualization. There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure. Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5. Once this was identified, foraminotomies were created to allow additional mobility. The wound was then copiously irrigated with antibiotic solution and suctioned dry. Working type screws, provisional titanium screws were then placed at L4-l5. This was to allow distraction and reduction of the spondylolisthesis. These were placed in the pedicles of L4 and L5 under direct intensification. The position of the screws were visualized, both AP and lateral images. They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5. This allowed for additional decompression of the L5 and L4 nerve roots. Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed. Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval. This was taken in sequence up to a 13 mm space. This was then reduced to a 11 mm as it was much more anatomic in nature. Once this was completed, the spacers were then placed on the left side and distraction obtained. Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally. Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried. A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft. There were impacted at the interspace of L4-L5 under direct image intensification. Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried. The provisional screws and plates were removed. This allowed for additional compression along L4-L5 with the cage instrumentation. Permanent screws were then placed at L4, L5, and S1 bilaterally. This was performed under direct image intensification. The position was verified in both AP and lateral images. Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone. The wound was then copiously irrigated with antibiotic solution and suction dried. The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally. A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1. Appropriate cross connecters were applied and the construct was placed over the pedicle screws. They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra. Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory. All connections were tightened and retightened in Torque 2 specifications. The wound was then copiously irrigated with antibiotic solution and suction dried. The dura was inspected and noted to be free of tension. At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors. An 8-inch Hemovac drain was placed exiting the wound. The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin. The remainder of the Hemovac was assembled. Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape. He was turned and taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded." }

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

{ "text_length": 7461 }

{ "text": "PROCEDURES:,1. Right and left heart catheterization.,2. Coronary angiography.,3. Left ventriculography.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.,IMPRESSION:,1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2. Severe mitral regurgitation.,3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.," }

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

{ "text_length": 2432 }

{ "text": "EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia." }

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

{ "text_length": 791 }

{ "text": "EXTERNAL EXAMINATION: , The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. A 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. The opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found. ,The body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. The body is cold and unembalmed. Lividity is fixed in the distal portions of the limbs. The eyes are open. The irises are brown and corneas are cloudy. Petechial hemorrhaging is present in the conjunctival surfaces of the eyes. The pupils measure 0.3 cm. The hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point. ,Removal of the belt revealed a ligature mark (known throughout this report as Ligature A) on the neck below the mandible. Ligature A is approximately 1.5 inches wide and encircles the neck in the form of a \"V\" on the anterior of the neck and an inverted \"V\" on the posterior of the neck, consistent with hanging. Minor abrasions are present in the area of Ligature A. Lack of hemorrhage surrounding Ligature A indicates this injury to be post-mortem. ,Upon removal of the victim's clothing, an odor of bleach was detected. Areas of the body were swabbed and submitted for detection of hypochlorite. Following removal of the shirt, a second ligature mark (known throughout this report as Ligature B) was observed on the victim's neck. The mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. The width of the mark varies between 0.8 and 1cm and is horizontal in orientation. The skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. Ligature B is not consistent with the belt that caused Ligature A. The absence of abrasions associated with Ligature B, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. No trace evidence was recovered from Ligature B that might assist in identification of the ligature used. ,The genitalia are that of an adult female and there is no evidence of injury. Pubic hair has been shaved in its entirety within six hours of death. Limbs are equal, symmetrically developed and show no evidence of injury. The fingernails are medium length and fingernail beds are blue. There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION: ,HEAD--CENTRAL NERVOUS SYSTEM: ,Subsequent autopsy shows a broken hyoid bone. Hemorrhaging from Ligature B penetrates the skin and subdermal tissues of the neck. The brain weighs 1,303 grams and within normal limits. ,SKELETAL SYSTEM:, The hyoid bone is fractured. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. Petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. Otherwise, the mucosa is intact and there are no injuries to the lips, teeth or gums. ,There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The hyoid bone, the thyroid, and the cricoid cartilages are fractured. ,The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM: ,The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM: ,The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. There is evidence of recent sexual activity but no indications that the sexual contact was forcible. Vaginal fluid samples are removed for analysis. ,TOXICOLOGY: ,Sample of right pleural blood and bile are submitted for toxicologic analysis. Stomach contents are saved. ,SEROLOGY:, A sample of right pleural blood is submitted in the EDTA tube. Routine toxicologic studies were ordered.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,Drug Screen Results:,URINE SCREEN {IMMUNOASSAY} WAS NEGATIVE. ,Ethanol: 0 gm/dl, Blood (Heart),Ethanol: 0 gm/dl, Vitreous ,EVIDENCE COLLECTED:,1. One (1) white turtleneck sleeveless shirt, size Small. ,2. One (1) pair navy blue sweatpants, size Small.,3. Two (2) silver hoop earrings. ,4. One (1) silver bracelet.,5. Samples of Blood (type O+), Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,6. Fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.,7. Eleven (11) autopsy photographs. " }

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

{ "text_length": 5803 }

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

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

{ "text_length": 1741 }

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

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

{ "text_length": 5880 }

{ "text": "Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:, Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired. Denies tobacco or ethanol use.,FAMILY HISTORY:, Father died of mesothelioma. Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:, Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN: ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time.," }

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

{ "text_length": 1727 }

{ "text": "SUBJECTIVE: , This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. General exam: The patient is nontoxic and in no acute distress. There is no labored breathing. Psychiatric: He is alert and oriented times 3. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Eyes: Pupils equal, round, and reactive to light bilaterally. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing.,ASSESSMENT: ,1. Palpitations, possibly related to anxiety.,2. Fatigue.,3. Loose stools with some green color and also some nausea. There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks. He says his work is definitely contributing to some of his symptoms and he feels stressed. He is leaving for a vacation very soon. Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him. My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. A 12-lead EKG was performed on him in the office today. This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news. I am going to send him to the lab from our office to get the following tests done: Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray. Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital. We were able to squeeze him in. His appointment is at 8:15 in the morning. He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. I am not going to be here so he is going to see Dr. X. Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ. Certainly, if something comes up we may need to postpone his trip. We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety. I talked about Ativan, how it works. I talked about the side effects. I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. I took him off of work today and tomorrow so he could rest." }

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

{ "text_length": 4160 }

{ "text": "ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:, Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:, None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure. She tolerated without difficulty. She had her pain controlled with p.o. pain medicine. She was afebrile. She is tolerating liquid diet. It was felt that the patient is stable for discharge. She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs. We will check a UA and urine culture prior to discharge. I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain. Her labs were within normal limits. She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related. Her labs in terms of her bilirubin were within normal limits. Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed. They were 51 and 83 for the AST and ALT respectively. I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower. She needs to keep her wound clean and dry. She is not to engage in any heavy lifting greater than 10 pounds x2 weeks. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility. She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:, We will follow up on both urinalysis and cultures. She is instructed to follow up with Dr. X in 2 weeks. She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds." }

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

{ "text_length": 2269 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1. Endoscopic release of left transverse carpal ligament.,2. Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA: ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:, With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mmHg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate. The Agee Inside Job was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision. After complete division of transverse carpal ligament, the Agee Inside Job was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished. One mL of Celestone was then introduced into the carpal tunnel and irrigated free. ,The wound was then closed with a running 3-0 Prolene subcuticular stitch. Steri-strips were applied and a sterile dressing was applied over the Steri-strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL. A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well." }

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

{ "text_length": 2938 }

{ "text": "CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a \"rubber-band\" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a \"boomerang\" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly \"too high\" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild \"concussion\" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia." }

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

{ "text_length": 5412 }

{ "text": "SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her. The patient is a well-developed baby. Appears stated age. Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies.,CURRENT MEDICATIONS:, None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:, Atopic eczema.,TREATMENT:,1. Discussed condition and treatment with Mom.,2. Continue bathing twice a week.,3. Discontinue hot soapy water.,4. Discontinue Elidel for now.,5. Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch. We will see her in one month if not better otherwise on a p.r.n. basis. Send a letter to ABC Practice program." }

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

{ "text_length": 1158 }

{ "text": "CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were \"negative.\" He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but \"non-surgical\" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC." }

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

{ "text_length": 3248 }

{ "text": "SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back." }

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

{ "text_length": 1165 }

{ "text": "CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology." }

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

{ "text_length": 3790 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1. Esophagogastroduodenoscopy with photo.,2. Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:, IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY: ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA. The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure. The patient also had neuromuscular dysfunction. After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family. First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus. Esophagitis was noted. The scope was then passed through the esophagus into the stomach. The cardia, fundus, body, and antrum of the stomach were visualized. There was evidence of gastritis. The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus. Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement. The skin was then anesthetized with 1% lidocaine. The finder needle was then inserted under direct visualization. The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth. The Ponsky PEG tube was attached to the wire. A skin nick was made with a #11 blade scalpel. The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position. The endoscope was then replaced confirming position. Photograph was taken. The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well. We will begin tube feeds later this afternoon." }

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

{ "text_length": 2521 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1. Postdates pregnancy.,2. Failure to progress.,3. Meconium stained amniotic fluid.,OPERATION:, Primary low-transverse C-section.,ANESTHESIA:, Epidural.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner. Anesthesia was tested and found to be adequate. Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally. Bleeders were bovied. Rectus muscles were separated from the overlying fascia with blunt and sharp dissection. Muscles were separated in the midline. Peritoneum was entered sharply and incision was carried out laterally in each direction. Bladder blade was placed and bladder flap developed with blunt and sharp dissection. A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction. Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance. Infant was carefully suctioned after delivery of the head and body. Cord blood was collected. _______ and endometrial cavity was wiped free of membranes and clots. Lower segment incision was inspected. There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic. Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present. Cul-de-sac was suctioned free of blood and clots and irrigated. Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated. Lower segment incision was again inspected and found to be hemostatic. The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin. Hemostasis was present between all layers. The area was gently irrigated across the peritoneum and fascial layers. There were no intraoperative complications except blood loss. The patient was taken to the recovery room in satisfactory condition." }

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

{ "text_length": 2500 }

{ "text": "REASON FOR VISIT: ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:, The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. She has not been having any headaches. She has had a significant decrease in appetite. She is known to have lung cancer, but Ms. Wilson does not know what kind. According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung. The last note I have to evaluate is from October 2008. CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion. I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand. She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:, Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS: ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED: ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE: ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter. The patient' daughter remained present throughout the procedure. The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture. During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort. The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table. Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT: ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending." }

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

{ "text_length": 3039 }

{ "text": "REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximately one time per week. These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve. Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. She states that she feels fatigued all the time and does not get good sleep. She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. She thinks she may snore, but she is not sure. She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY: ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS: ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination: Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION: ,As before is nonfocal. Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. The nature of this lesion is unclear. Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1. Left facial twitching-appears to be improving. Most likely, this is a peripheral nerve injury related to her abscess as previously described. In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2. Posterior pressure like headache, also appears to be improving. The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3. Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. She is on vacation next week and is going to try to see if this will help. We also discussed as before weight loss and exercise, which could be helpful.,4. Right clivus and petrous lesion of unknown etiology. We will repeat the MRI at four months to see for interval change.,5. The patient voiced understanding of these plans and will be following up with me in five months." }

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

{ "text_length": 4031 }

{ "text": "CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS: ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:, Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:, CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1. HEMATURIA.,2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3. SIGNIFICANT ANEMIA.,4. URINARY OBSTRUCTION.,CONDITION ON DISPOSITION: ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern." }

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

{ "text_length": 8482 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This is a 77-year-old male, who presents with gross hematuria that started this morning. The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too. He is complaining of no other pain. He denies any abdominal pain. Denies any bleeding anywhere else. Denies any bruising. He had an episode similar to this a year ago where it began the same with hematuria. He was discharged after a workup in the hospital, in the emergency room, with Levaquin. Three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding. His H and H was down in the 6 level. He received blood transfusions. He was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition. Family actually states that they were told that he was unlikely to live through that event, but he did. Since then, he has had no bleeding. The patient has had no fever. No cough. No chest pain or shortness of breath. No bleeding gums. No blurred vision. No headache. No recent falls or trauma. He has had no nausea or vomiting. No diarrhea. No blood in the stool or melena. No leg or calf pain. No joint pain. No rashes. No swollen glands. He has no numbness, weakness or tingling to his extremities. No acute anxiety or depression.,PAST MEDICAL HISTORY: , Has prostate cancer.,MEDICATION: , He is receiving Lupron injection by Dr. Y. The only other medication that he takes is Tramadol.,SOCIAL HISTORY: , He does not smoke or drink.,PHYSICAL EXAMINATION:,Vital Signs: Are all reviewed on triage.,General: He is alert. Answers slowly with a speech impediment, but answers appropriately.,HEENT: Pupils equal, round, and reactive to light. Normal extraocular muscles. Nonicteric sclerae. Conjunctivae are not pale. His oropharynx is clear. His mucous membranes are moist.,Heart: Regular rate and rhythm, with no murmurs.,Lungs: Clear.,Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No organomegaly or mass.,Extremities: No calf tenderness, erythema or warmth. He has no bruises noted.,Neurological: Cranial nerves II through XII are intact. He has 5/5 strength throughout. ,GU: Normal.,LABORATORY DATA: ,The patient did on urinalysis have few red blood cells. His urine was also grossly red, although no blood clots or gross blood was noted. It was more of a red fluid. He had a mild decrease in H and H at 12.1 and 34.6. His white count was normal at 7.2. His PT was elevated at 15.9. PTT elevated at 36.4. INR is 1.4. His comprehensive metabolic profile is normal except for BUN of 19.,CONDITION: , The patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with Dr. X and he is admitted for orders. Also we will consult Dr. Y, see orders for further." }

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

{ "text_length": 3001 }

{ "text": "PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.,IMPRESSION: ,Normally functioning pacemaker ICD post implant day number 1." }

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

{ "text_length": 1366 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 39 plus weeks gestation.,2. Gestational hypertension.,3. Thick meconium.,4. Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1. Intrauterine pregnancy at 39 plus weeks gestation.,2. Gestational hypertension.,3. Thick meconium.,4. Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:, 500 mL.,COMPLICATIONS: , Thick meconium. Severe variables, Apgars were 2 and 7. Respiratory therapy and ICN nurse at delivery. Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks. She was already 3 cm dilated. She had artificial rupture of membranes. Pitocin was started and she actually went to complete dilation. While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations. When she was complete +2, vacuum attempted delivery, three pop-offs were done. The vacuum was then no longer used after the three pop-offs. The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear. Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery. Baby was delivered floppy. Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist. Delivery of intact placenta and three-vessel cord. Third-degree midline tear was repaired with Vicryl without any complications. Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there. Again, mother and baby are both doing well. Mother will go to Postpartum and baby is already in Newborn Nursery." }

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

{ "text_length": 2104 }

{ "text": "EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above." }

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

{ "text_length": 1109 }

{ "text": "PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:, A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation. The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating. The following day he noted increasing pain and first noted blood on the surface of his stool. The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge. The patient denies any previous history of rectal bleeding or pain. He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative. The patient does state that he has not felt well for the past week. He states that he had felt \"feverish\" on several occasions but has not taken his temperature. He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue. He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13. He admits to eight previous partners and states that he \"usually\" uses a condom. On further questioning, the patient states that of his eight partners, three were female and five were male. His most recent sexual partner was a 38-year-old man whom he has been with for the past six months. He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing. He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy. The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family. As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life. He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men. He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT: Several areas of white plaque-like material on the buccal mucosa.,Neck: Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs: Clear to auscultation.,Cardiac: Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen: Soft without hepatosplenomegaly.,GU: Tanner V male with no external penile lesions.,Lymph: 2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal: Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12. 5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab: numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge. The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination. The following are in the differential diagnosis: Acute Proctitis and Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use. Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion. The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD. The patient could experience more systemic symptoms with fever and malaise, as found with this patient. However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS: ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae. An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult. First, the patient utilized the emergency department for care as opposed to identifying a primary care provider. Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed. Second, this young man has had both male and female sexual partners. As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors. Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions. Third, screening for STDs must take into account sexual behaviors. Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections. If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs. Fourth, this young man had both localized and systemic symptoms. As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation. In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered. The care provided to this young man included the following. He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis. Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae. At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program. The case manager linked this young man directly to care after providing brief counseling and support. The case manager maintained contact with the young man until his first clinical visit four days later. Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL" }

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

{ "text_length": 6676 }

{ "text": "HISTORY: ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning. Then, the patient was noted to vomit after feeds. The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range. The patient underwent a barium enema, which was read by the radiologist as negative. The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital. Birth weight was 6 pounds 4 ounces. There was maternal hypertension. Mother denies group B strep or herpes. Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: ,Here with mother and grandmother, lives at home. There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS: ,The patient is fed Enfamil, bottle-fed. Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL: On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle. Pupils are equal, round, and reactive to light. Grossly conjugate. Bilateral red reflex appreciated bilaterally. Clear TMs, nose, and oropharynx. There is a kind of abundant thrush and white patches on the tongue.,NECK: Supple, full, painless, and nontender range of motion.,CHEST: Clear to auscultation, equal, and stable.,HEART: Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN: Soft and nontender. No hepatosplenomegaly or masses.,GENITALIA: Female genitalia is present on a visual examination.,SKIN: No significant bruising, lesions, or rash.,EXTREMITIES: Moves all extremities, and nontender. No deformity.,NEUROLOGICALLY: Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome. The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos. Serum electrolytes not normal. Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4. AST and ALT were elevated as well at 412 and 180 respectively. A cath urinalysis showing no signs of infection. Spinal fluid evaluation, please see procedure note below. White count 0, red count 2060. Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain. The fluid was obtained, the needle was removed, and sterile bandage was placed. The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well. An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12. A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast. Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids. Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued. The patient was admitted to the Hospitalist Service for continued IV fluids. The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula. She has not had any vomiting, is burping. The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration. Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service." }

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

{ "text_length": 5509 }

{ "text": "OPERATIVE PROCEDURE:, Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:, Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina. Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. The patient tolerated the procedure well. Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:, Pneumonia, infiltrates." }

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

{ "text_length": 1097 }

{ "text": "XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin at this point. Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use. His physical exam, neurologically, is normal at this time. His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time. I understand this will probably entail repeating his EEG and so please coordinate this through Health Center. I await your response and whether we should continue this medication. If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling." }

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

{ "text_length": 1063 }

{ "text": "PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, Sedation with local.,COMPLICATIONS:, None.,CONDITION:, Fair.,DISPOSITION:, PACU.,ACCESS SITE:, Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS: ,The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:, The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.,IMPRESSION,1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation." }

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

{ "text_length": 6937 }

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

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

{ "text_length": 2924 }

{ "text": "CHIEF COMPLAINT,: This 32 year-old female presents today for an initial obstetrical examination. Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy). LMP: 02/13/2002 EDD: 11/20/2002 GW: 8.0 weeks. Patient has been trying to conceive for 6 months.,Menses: Onset: 12 years old. Interval: 24-26 days. Duration: 4-6 days. Flow: moderate. Complications: PMS - mild.,Last Pap smear taken on 11/2/2001. Contraception: Patient is currently using none.,ALLERGIES:, Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness. Medication History: None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of tonsillectomy in 1980. Social History: Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding. Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:, BP Standing: 126/84 Resp: 22 HR: 78 Temp: 99.1 Height: 5 ft. 6 in. Weight: 132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed,,well nourished and with good attention to hygiene and body habitus.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face: Examination of head and face is unremarkable.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. No edema observed.,Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory: Lungs CTA.,Breast: Chest (Breasts): Breast inspection and palpation shows no abnormal findings.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary: External genitalia are normal in appearance. Examination of urethra shows no abnormalities. Examination of vaginal vault reveals no abnormalities. Cervix shows no pathology. Uterine portion of bimanual exam reveals contour normal, shape regular and size normal. Adnexa and parametria show no masses, tenderness, organomegaly or nodularity. Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test: positive. CBC results within normal limits. Blood type: O positive. Rh: positive. FBS: 88 mg/dl.,IMPRESSION:, Pregnancy, normal first. Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:, Pap smear submitted for manual screening. Ordered CBC. Ordered blood type. Ordered hemoglobin. Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:, Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity. Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:, NatalCare Plus Dosage: Prenatal Multivitamins tablet Sig: QD Dispense: 60 Refills: 4 Allow Generic: Yes,PATIENT INSTRUCTIONS:, Patient received written information regarding pre-eclampsia and eclampsia. Patient was instructed to restrict activity. Patient instructed to limit caffeine use. Patient instructed to limit salt intake." }

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

{ "text_length": 3747 }

{ "text": "CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:, None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day.,SOCIAL HISTORY: ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings.,HEART: Regular rate and rhythm, without murmur. Normal S1, S2.,LUNGS: Clear. No rales. No wheeze. Good excursion.,ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES: No edema, clubbing, or cyanosis. No rash.,LABORATORY FINDINGS: , On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1. Hypoglycemia due to not eating her meals on a regular basis.,2. Hypertension.,3. Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication." }

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

{ "text_length": 2555 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES: ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION: ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week." }

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

{ "text_length": 1630 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C3-4.,2. Arthrodesis with anterior interbody fusion, C3-4.,3. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT: ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS: ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: ,Less than 100 mL.,CONDITION: ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION: ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop. Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening. About two days ago, he started noticing weakness on the left arm. The patient also noted shuffling gait. The patient presented to a family physician and was referred to Dr. X for further evaluation. Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine. MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes. Based on these findings, I recommended decompression. The patient was started on Decadron at 10 mg IV q.6h. Operation, expected outcome, risks, and benefits were discussed with him. Risks to include but not exclusive of bleeding and infection. Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function. Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient. There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics. However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation. This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed. There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele. This too can compromise airway and may require return to the operating room for repair of the dural tear. There is also potential risk of injury to the esophagus, the trachea, as well as the carotid. The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. No monitoring leads were placed. The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. Localizing x-ray verified the marker to be right at the C3-4 interspace. Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath. The prevertebral fascia was identified. Localizing x-ray verified another marker to be at the C3-4 interspace. Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out. There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur. The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side. By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed. Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder. With this completed, the Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant with its interior packed with Vitoss was then tapped into place. An 18-mm plate was then screwed down with four 14 x 4.0 mm screws. The area was irrigated with saline, with bacitracin solution. Postoperative x-ray showed excellent placement of the graft and spinal instrumentation. A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond. The catheter was anchored to the skin with a nylon 3-0 stitch. Dressing was placed only on the exit site of the drain. C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities." }

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

{ "text_length": 6766 }

{ "text": "SUBJECTIVE:, This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes. She did attend diabetes education classes at Abc Clinic. She comes however, wanting to really work at weight reduction. She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds. She is now following a veggie diet which she learned about in Poland originally. She has been on it for three weeks and intends to follow it for another three weeks. This does not allow any fruits or grains or starchy vegetables or meats. She does eat nuts for protein. She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet. She also wants to know that if she gets skinny enough, if the diabetes will go away. Her problem time, blood sugar wise, is in the morning. She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:, Weight: 189 pounds. Reported height: 5 feet 5 inches. BMI is approximately 31-1/2. Diabetes medications include metformin 500 mg daily. Lab from 5/12/04: Hemoglobin A1C was 6.4%.,A diet history was obtained. I instructed the patient on dietary guidelines for weight reduction. A 1200-calorie meal plan was recommended.,ASSESSMENT:, Patient's diet history reflects that she is highly restricting carbohydrates in her food intake. She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning. This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts. She is doing some physical activity two to three times a week. This includes aerobic walking with weights on her arms and her ankles. She is likely going to need to increase frequency in this area to help support weight reduction. Her basal metabolic rate was estimated at 1415 calories a day. Her total calorie requirements for weight maintenance are estimated at 1881 calories a day. A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:, Recommend patient increase the frequency of her walking to five days a week. Encouraged a 30-minute duration. Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations. And lastly, I encouraged caloric intake of just under 1200 calories daily. Recommend keeping food records and tracking caloric intake. It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage. However, I encouraged her to be careful not to reduce calories below 1000 calories daily. She may want to consider a multivitamin as well. This was a one-hour consultation." }

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

{ "text_length": 2844 }

{ "text": "REASON FOR VISIT:, The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped. Vitamin D and calcium over the counter, we need to verify that. Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:, On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress. There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum. Stasis dermatitis changes in both lower extremities present. Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well. Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228. Her microcytosis and hypochromia has resolved. Her serum electrophoresis does not show a monoclonal abnormality. Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation. This points again towards some ileum pathology. Her ANCA B and C were negative. Her PF3 and MPO were unremarkable. Her endomysial antibodies were negative. Her sed rate at this time were 19. The highest has been 30, but prior to her appointment here was even higher. Her ANA continues to be positive with a titer of 1:40, speckled pattern. Her double-stranded DNA is negative. Her serum immunofixation confirmed the absence of monoclonal abnormality. Her urine immunofixation was not performed. Her IgG, IgA, and IgM levels are normal. Her IgE levels are normal as well. A urinalysis was not performed this time. Her CRP is 0.4. Her tissue transglutaminase antibodies are negative. Her ASCA is normal and anti-OmpC was not tested. Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific. I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal. Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency. Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30. Her TIBC was 345 pointing towards an iron deficiency anemia. I am reminding you that her ACE levels in the past were normal and that she has a microcytosis. Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive. Her pelvic ultrasound showed normal uterus adnexa. Her bladder was normal as well. Subcentimeter inguinal nodes were found. There was no large lytic or sclerotic lesion noted. Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease. Her capsule endoscopy was limited secondary to rapid transit. There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum. However, no significant inflammation or bleeding was seen and this could be small bowel crisis. Neither evidence of bleeding or inflammation were seen as well. Specifically, the terminal ileum appeared normal. Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:, This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. Since I took over her care, I have not seen a clear-cut erythema nodosum being present. No evidence of synovitis was there. Her serologies apart from an ANA of 1:40 were negative. She has a livedo pattern, which has been worrisome. The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV. We never received the x-ray of her hands which she had and she never had a DEXA scan. Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well. Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal. We are going check a PPD to rule out tuberculosis. We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. An anti-intrinsic factor will be added as well. Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency. In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. Regarding her heart murmur, we are going to proceed with an echocardiogram. A PPD should be placed as well. In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:, 1. Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2. Iron deficiencies, according to iron studies.,3. Borderline B12 with increased methylmalonic acid and homocystine.,4. On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5. Typical ANCA, per records, were not verified here. ANCA and ASCA were negative and the OmpC was not ordered.,6. Acne.,7. Recurrent arthralgia not present. Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8. Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today. Needs vaccination for influenza and pneumonia.,9. Vitamin D deficiency. She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10. Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:, We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. She should be taking vitamin D and calcium after the completion of vitamin D replacement. She should be seen by her primary care physician, have the iron and B12 deficiency worked up. She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies. Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum. An anti-intrinsic factor would be added, as I mentioned. I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers. She does not give a history of oral contraceptives or medications that could be related to erythema nodosum. She does not have any evidence of lupus __________ mycosis. Histoplasmosis coccidioidomycosis would be accompanied by other symptoms. Hodgkin disease has probably been ruled out with a CAT scan. However, we are going to add an LDH in future workup. I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. The patient will return in 1 month." }

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

{ "text_length": 14518 }

{ "text": "HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3. Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively. Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency. She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards. She complained of sweating, but has experienced no diarrhea and no change in appetite. She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:, Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:, She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use.,MEDICATIONS:, Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT: She has exophthalmos and could not close her lids completely.,Cardiovascular: tachycardia.,Neurologic: She had mild hyperreflexiveness.,LAB:, All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry. On the 2nd day of treatment, the patient still complained of chest pain. EKG again showed tachycardia. Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours. The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake. Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131. She was to return home after the iodine treatment. She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism. Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism. Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism. She should return to Endocrine Clinic in six weeks to have thyroid function tests performed. Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy. Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health. Patient was given methylcellulose ophthalmic, one drop in each eye daily. She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression. Patient will be continued on citalopram 10 mg." }

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

{ "text_length": 3264 }

{ "text": "GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM. Fetal Lie: Longitudinal. Fetal Presentation: Cephalic. Placenta: Anterior Grade I. Uterus: Normal. Cervix: Closed. Adnexa: Not seen. Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:" }

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

{ "text_length": 404 }

{ "text": "REASON FOR EXAM:,1. Angina.,2. Coronary artery disease.,INTERPRETATION: ,This is a technically acceptable study.,DIMENSIONS: ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.,FINDINGS: , Left atrium was mildly to moderately dilated. No masses or thrombi were seen. The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. The EF was moderately reduced with estimated EF of 40% with near normal thickening. The right atrium was mildly dilated. The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation. There was mild mitral regurgitation on color flow interrogation. The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. The aortic valve appeared to be structurally normal. Normal peak velocity. No significant AI. Pulmonic valve showed mild PI. Tricuspid valve showed mild tricuspid regurgitation. Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg. Anterior septum appeared to be intact. No pericardial effusion was seen.,CONCLUSION:,1. Mild biatrial enlargement.,2. Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3. Mild mitral regurgitation.,4. Diastolic dysfunction grade 2.,5. Mild pulmonary hypertension." }

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

{ "text_length": 1491 }

{ "text": "PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty. The right arm, axilla, and chest wall were prepped and draped in sterile fashion. Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent. The draining veins are the deep brachial veins. The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture. A nice length of vein was obtained to the distal one third of the arm. This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein. A transverse skin incision was made over the superior aspect of the old fistula vein. This vein was carefully dissected out and encircled with vascular tapes. The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula. The patient was sensible, was then systemically heparinized. The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter. The brachial vein end was spatulated. Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion. After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled. The anastomosis was completed. A nice thrill could be palpated over the outflow brachial vein. Hemostasis was noted. A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture. The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin. Sterile dressings were applied. The patient was then x-ray'd and taken to Recovery in satisfactory condition. Estimated blood loss 50 mL, drains 8 mm Blake. Operative complication none apparent, final sponge, needle, and instrument counts reported as correct." }

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

{ "text_length": 2435 }

{ "text": "DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is \"dormant.\",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:" }

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

{ "text_length": 5185 }

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

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

{ "text_length": 7937 }

{ "text": "She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when it comes can last for half-a-day. It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She was seen at XYZ where blood work was done. At that time, she had a normal white count and a normal H&H. She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done. This showed a 1.9 x 1.4-cm cyst on the right with no free fluid. The left ovary and uterus appeared normal. Two days later, the pain resolved and she has not had a recurrence. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping which she is not happy about.,She has never had a pelvic exam. She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present. She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX: ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX: ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS: ,Zoloft 50 mg a day and LactAid.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking. She does have a boyfriend; again she states she is not sexually active. She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age. She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches. Weight: 190 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology. I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this. However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill. She has no personal or familial contraindications to start this. She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4. She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call." }

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

{ "text_length": 3550 }

{ "text": "SUBJECTIVE:, This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. The patient is in foster care, has a long history of the prematurity, born at 22 weeks. She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic. She is on 2-1/2 liters of oxygen and does require that. Her diet has been fluctuating. They have been trying to figure out what works best with her. She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her. They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure. She was hospitalized a couple of weeks back for the distension she had in the abdomen. Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking. She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:, Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:, As mentioned, she is in foster care. Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient. Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:, The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs: She is 28 pounds 8 ounces today, 33-1/2 inches tall. She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT: Sclerae and conjunctivae are clear. TMs are clear. Nares are patent. Oropharynx is clear. Trach site is clear of any signs of infection.,Chest: Coarse. She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen: Positive bowel sounds and soft. The G-tube site looks fairly clean today and healthy. No signs of infection. Her tone is good. Capillary refill is less than three seconds.,ASSESSMENT:, A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:, At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure. They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum. I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand. She is just doing wonderful progression on her development. Each time I see her, I am very impressed, that relayed to foster mom. Approximately 25 minutes spent with the patient, most of it counseling." }

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

{ "text_length": 3516 }

{ "text": "EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord." }

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

{ "text_length": 2412 }

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

{ "text_length": 2231 }

{ "text": "SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs: The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004. I praised her weight loss and her regular exercising. I looked at her food journal. I praised her record keeping. I gave her a list of the diabetic exchanges and explained them. I also gave her a food dairy sheet so that she could record exchanges. I encouraged her to continue.,ASSESSMENT:, The patient seems happy with her progress and she seems to be doing well. She needs to continue.,PLAN:, Followup is on a p.r.n. basis. She is always welcome to call or return." }

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

{ "text_length": 1037 }

{ "text": "PREPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,PROCEDURE DETAIL:, After obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up. The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% Xylocaine 20 mL and Marcaine 0.25% 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized. A total of 30 mL worth of solution was used. I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,The patient tolerated the procedure well. She had no respiratory distress. Immediately, the patient felt some relief from the pain. Chest x-ray was ordered for the following day." }

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

{ "text_length": 1203 }

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

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

{ "text_length": 5910 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,PROCEDURE PERFORMED: ,Excision of left breast mass and revision of scar.,ANESTHESIA: ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION: ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY: ,The patient is an 18-year-old female who presented to Dr. X's office. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. The patient also has a hypertrophic scar. Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed. The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion. Elliptical incision was made over the previous cicatrix. The total length of the incision was 5.5 cm. Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine. Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery. Hemostasis was maintained. Attention was next made to approximating the deep dermal layers. An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges. Steri-Strips as well as bacitracin and sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition." }

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

{ "text_length": 2044 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS: ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance. She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY: ,The patient was brought to the operative suite and placed supine on the operating room table. General anesthetic was administered. Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy. He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx. Under an operating headlight, the oropharynx was clearly visualized. The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa. This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris. Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts. With the tonsils removed, it was possible to visualize the adenoid pads. The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique. The adenoid pad was greater than 2+/4 and hypertrophic. It was removed with successive passes of electrocautery suction. The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle. The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period. The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic. She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal. There were no complications. Specimens produced were right and left tonsils. The adenoid pad was ablated with electrocautery." }

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

{ "text_length": 2691 }

{ "text": "CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,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. No calvarial fracture is seen.,IMPRESSION: ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE: ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:, There is no facial bone fracture. The maxilla and mandible are intact. The visualized paranasal sinuses are clear. The temporomandibular joints are intact. The nasal bone is intact. The orbits are intact. The extra-ocular muscles and orbital nerves are normal. The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen. The vertebral body heights are normal. The intervertebral disk spaces are well preserved. The atlanto-dens interval is normal. No abnormal anterior cervical soft tissue swelling is seen. There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture." }

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

{ "text_length": 1606 }

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

{ "text_length": 4262 }

{ "text": "As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having \"overactive bladder\", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable \"stiffness\" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was \"not arthritis\", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could \"barely walk\". She felt as if her balance is impaired and she felt as if she were \"walking on stilts\". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of \"good nutrition, vitamin supplements, and fish oil\".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to \"look better\". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements." }

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

{ "text_length": 7832 }

{ "text": "REASON FOR EXAM:, CVA.,INDICATIONS: , CVA.,This is technically acceptable. There is some limitation related to body habitus.,DIMENSIONS: ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated. No masses or thrombi were seen. The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%. The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve. The valve itself was structurally normal. No vegetations seen. No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1. The aortic valve showed minimal thickening with good exposure and coaptation. Peak velocity is normal. No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained. A bubble study was not performed.,No pericardial effusion was seen. Aortic arch was not assessed.,CONCLUSIONS:,1. Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2. Mitral annular calcification with structurally normal mitral valve.,3. No intracavitary thrombi is seen.,4. Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained." }

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

{ "text_length": 1433 }

{ "text": "EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual." }

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

{ "text_length": 621 }

{ "text": "CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap: 1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable. Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent. Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day. Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C. 1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 104. BP: 100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses. No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery. Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days. Doxycycline 100 mg #14 1 BID." }

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

{ "text_length": 2994 }

{ "text": "NERVE CONDUCTION STUDIES:, Bilateral ulnar sensory responses are absent. Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. The left radial sensory response is normal and robust. Left sural response is absent. Left median motor distal latency is prolonged with attenuated evoked response amplitude. Conduction velocity across the forearm is mildly slowed. Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity. The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow. Conduction velocities across the forearm and across the elbow are prolonged. Conduction velocity proximal to the elbow is normal. The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist. There is mild diminution of response around the elbow. Conduction velocity slows across the elbow. The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head. F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle. It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles. There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. A sensory motor length-dependent neuropathy consistent with diabetes.,2. A severe left ulnar neuropathy. This is probably at the elbow, although definitive localization cannot be made.,3. Moderate-to-severe left median neuropathy. This is also probably at the carpal tunnel, although definitive localization cannot be made.,4. Right ulnar neuropathy at the elbow, mild.,5. Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6. A left C8 radiculopathy (double crush syndrome).,7. There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin. He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch. He is still scheduled for MRI of C-spine and T-spine. I will see him in followup after the above scans." }

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

{ "text_length": 2698 }

{ "text": "DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she was positive Nitrazine, no ferning was noted. On ultrasound, her AFI was about 4.7 cm. Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin. Once she was in her regular pattern, we ruptured her bag of water; fluid was clear. She went rapidly to completion over the next hour and a half. She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation. Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. The baby was vigorous, moving all extremities. The cord was clamped and cut. The baby was handed off to mom with nurse present. Apgars were 8 and 9. Placenta was delivered spontaneously, intact. Three-vessel cord with no retained placenta. Estimated blood loss was about 150 mL. There were no tears." }

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

{ "text_length": 1250 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition." }

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

{ "text_length": 1016 }

{ "text": "HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains." }

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

{ "text_length": 1195 }

{ "text": "REASON FOR CONSULTATION:, Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out. As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion. According to the daughter, she has had episodes of weakness, but no syncope. She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode. At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE. Initial V/Q scan done at Hospital was negative. She was anticoagulated with Coumadin resulting in severe GI bleed. Anticoagulation was stopped and an IVC filter was placed at that time. She has a history of malignant hypertension and has had a renal stent placed in February 2007. She also has peripheral vascular disease with stent placements. There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath. There are no acute EKG changes or cardiac enzyme elevations. She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1. Coronary artery disease, status post coronary artery bypass grafting.,2. History of mitral regurgitation, unable to repair the valve.,3. History of paroxysmal atrial fibrillation, on amiodarone.,4. Gastroesophageal reflux disease.,5. Hypertension.,6. Hyperlipidemia.,7. History of abdominal aortic aneurysm.,8. Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9. Peripheral vascular disease.,10. Hypothyroidism.,11. Pulmonary embolism.,PAST SURGICAL HISTORY,1. Coronary artery bypass grafting.,2. Hysterectomy.,3. IVC filter.,4. Tonsillectomy and adenoidectomy.,5. Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1. Aspirin 81 mg once a day.,2. Klor-Con 10 mEq once a day.,3. Lasix 40 mg once a day.,4. Levothyroxine 125 mcg once a day.,5. Lisinopril 20 mg once a day.,6. Pacerone 200 mg once a day.,7. Protonix 40 mg once a day.,8. Toprol 50 mg once a day.,9. Vitamin B once a day.,10. Zetia 10 mg once a day.,11. Zyrtec 10 mg once a day.,ALLERGIES:, CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies any fevers, chills, recent weight gain or weight loss. She has had abdominal symptoms with diarrhea.,EYES: Decreased visual acuity.,ENT: Sinus drainage.,CARDIOVASCULAR: As described above. Denies any chest pains.,RESPIRATORY: He has chronic shortness of breath. No cough or sputum production.,GI: History of reflux symptoms.,GU: No history of dysuria or hematuria.,ENDOCRINE: No history of diabetes.,MUSCULOSKELETAL: Denies arthritis, but has leg pain.,SKIN: No history of rash.,PSYCHIATRIC: No history of anxiety or depression." }

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

{ "text_length": 3337 }

{ "text": "BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,: The patient is placed in the supine position, prepped and draped in the usual manner. Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision. Hemostasis was obtained with the Bovie and the spermatic cord was identified. It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief. The left testicle was delivered through the same incision. The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine. The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin. A dry sterile dressing fluff and scrotal support applied over that. The patient was sent to the Recovery Room in stable condition." }

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

{ "text_length": 991 }

{ "text": "TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer. The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease. Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer. Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed. The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others. The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL: ,After identifying the patient, the patient was placed supine on the operating room table. The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube. The eyes were protected with Tegaderm. The patient was rotated to 180 degrees towards the operating surgeon. The Foley catheter was placed into the bladder with good return of urine. Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately. A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip. The incision then was planned around the old scar to be excised. A 1% lidocaine with 1 to 100,000 epinephrine was injected. A shoulder roll was applied. The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly. Attention was then turned to performing the level 1 dissection on the left. Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible. The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve. Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric. The submandibular gland was appreciated and retracted laterally. The mylohyoid muscle appreciated. The lingual nerve was appreciated and the submandibular ganglion was ligated. The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis. The marginal mandibular nerve stimulated at the completion of this portion of the procedure. Attention was then turned to incising the fascia along the clavicle on the left side. Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified. The brachial plexus and phrenic nerve were identified. The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels. Attention was then turned to the central neck. The strap muscles were appreciated in the midline. There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature. A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed. Attention was then turned to identify the carotid artery and the internal jugular vein on the left side. This was traced inferiorly, internal jugular vein to the brachiocephalic vein. Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass. Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis. Attention was then turned to the right neck dissection. A posterior flap on the right was raised to the anterior border of the trapezius. The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly. Attention was then turned to identifying the submandibular gland. A digastric tunnel was performed back to the sternocleidomastoid muscle. The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated. The omohyoid muscle was retracted inferiorly. Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle. Subsequently the internal jugular vein was identified. The external jugular vein ligated about 1 cm above the clavicle. Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex. Dissection along the floor of the neck then was performed to allow for mobilization. The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass. Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated. The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly. The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base. The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein. The wound was copiously irrigated. Valsalva maneuver was given. No bleeding points identified. The wound was then prepared for closure. Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon. The wound was closed with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil. The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition." }

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

{ "text_length": 6847 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct." }

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

{ "text_length": 1243 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well." }

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

{ "text_length": 969 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,3. Enterogastritis.,PROCEDURE PERFORMED: ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature. She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently. She has had a history of hiatal hernia. She is being evaluated at this time for disease process. She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm. There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia. There is no advancement of the gastric mucosa up into the lower one-third of the esophagus. However there appeared to be inflammation as stated previously in the gastroesophageal junction. There was some mild inflammation at the antrum of the stomach. The fundus of the stomach was within normal limits. The cardia showed some laxity to the lower esophageal sphincter. The pylorus is concentric. The duodenal bulb and sweep are within normal limits. No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. The patient was given IV sedation using Demerol and Versed. Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus. Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted. Panendoscope was slowly withdrawn carefully examining the lumen of the bowel. Photographs were taken with the pathology present. Biopsy was obtained of the antrum of the stomach and also CLO test. The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis. Air was aspirated from the stomach and the panendoscope was removed. The patient sent to recovery room in stable condition." }

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

{ "text_length": 2232 }

{ "text": "PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:, Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass. On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy. The patient had good anterior support at the bladder. Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed. The patient understood all the risks and benefits and wanted to proceed with the procedure. Risk of retention and incontinence were discussed. Consent was obtained through the family members.,DETAILS OF THE OR:, The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed. The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support. A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part. Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring. Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive. Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis. Oral consent was obtained from the family and her surgery was preceded. The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors. Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus. The vaginal mucosa was pretty much completely closed off all the way up to the introitus. Indigo carmine was given. Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings. There was no injury to the bladder or kinking of the ureteral openings. The bladder was normal. Rectal exam was normal at the end of the colpocleisis repair. There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition." }

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

{ "text_length": 2894 }

{ "text": "SUMMARY: ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. She put out 1175 mL of urine since surgery. Her incision looks good. IV site and extremities are unremarkable.,LABORATORY DATA: ,Her calcium level was 7.5 this morning. She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:, I will heparin lock her IV, advance her diet, and ambulate her. I have asked her to increase her prednisone when she goes home. She will double her regular dose for the next five days. I will advance her diet. I will continue to monitor her calcium levels throughout the day. If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow. She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill. Her final calcium dosage will be determined prior to discharge. I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems." }

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

{ "text_length": 1210 }

{ "text": "FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve." }

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

{ "text_length": 2301 }

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

{ "text_length": 3988 }

{ "text": "CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size: 2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion: Present.,Margins: Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage: pT1N1MX." }

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

{ "text_length": 1646 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA. The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology. The patient states that this was started approximately 24 hours ago. The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain. The patient admits to poor dental hygiene. Denies any recent or dental abscesses in the past. The patient is a substance abuser, does admit to smoking cocaine approximately three days ago. The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted. After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE: ,The patient was brought in upright and supine position. Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side. This was done at the base of #18, #19, and #20 teeth. After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control. After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed. There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination. The patient understood consequences of her actions. Does state that she does not care at this time and just wants to be left alone. At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin. The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face." }

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

{ "text_length": 2736 }

{ "text": "REASON FOR NEUROLOGICAL CONSULTATION:, Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001. He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands. More recently, he describes a burning sensation along with numbness. This has become a particular problem and of all the problems he has he feels that pain is his primary concern. Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands. He denies any weakness per se, just clumsiness and decreased sensation. He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders. This has been a fairly longstanding problem, and again has become more prevalent recently. He does not have any tremor. He denies any neck pain. He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control. Oxycodone helps somewhat and gives him at least three hours pain relief. Because of the pain, he has significant problems with fractured sleep. He states he has not had a good night's sleep in many years. About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility. At that facility, his insulin was stopped. Since then he has only been on oral medication for his diabetes. He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart. He does not smoke. He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds. Pain scale 7/10. A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination. Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip. Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion. Tone and bulk are normal. Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally. He has no vibration sense at his knees. Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally. The only reflexes I could obtain with trace reflexes in his biceps. Remaining reflexes were unelicitable. No Babinski. The patient walks normally with the aid of a cane. He has severe sensory ataxia with inability to walk unaided. Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities. He has relative preservation of motor function. Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2. He has history of myoclonic jerks. I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy. I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1. EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2. Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3. Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d. Side effect profile of this medication was discussed with the patient.,4. I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5. I will see him at followup at the EMG." }

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

{ "text_length": 5174 }

{ "text": "TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:, Scans through the base of the brain are unremarkable. The oropharynx and nasopharynx are within normal limits. The airway is patent. The epiglottis and epiglottic folds are normal. The thyroid, submandibular, and parotid glands enhance homogenously. The vascular and osseous structures in the neck are intact. There is no lymphadenopathy. The visualized lung apices are clear.,IMPRESSION: ,No acute abnormalities." }

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

{ "text_length": 620 }

{ "text": "REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:, He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:, Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor." }

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

{ "text_length": 3019 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:, Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:, 1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40. The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery. All questions from the patient were answered after the surgical procedure was explained in detail. The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc. Alternative of the procedure is to do nothing or seek a second opinion. Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area. Previously, an intravenous infusion was begun at a keep vein open rate. After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye. A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine. An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area. Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted. Vital sign monitors were detached from the patient. The patient was moved to the operative suite and the same monitors were reattached. The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery. The speculum was set into place and the operative microscope was brought over the eye. The eye was examined. Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea. Then a pocket incision was created without entering the anterior chamber of the eye. Two peripheral paracentesis ports were created on each side of the initial incision site. Viscoelastic was used to deepen the anterior chamber of the eye. A 2.65 mm keratome was then used to complete the corneal valve incision. A cystitome was bent and created using a tuberculin syringe needle. It was placed in the anterior chamber of the eye. A continuous curvilinear capsulorrhexis was begun. It was completed using O'Gawa Utrata forceps. A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus. The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye. The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique. All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports. The posterior capsule remained intact throughout the entire procedure. Provisc was used to deepen the anterior chamber of the eye. A crescent blade was used to expand the internal aspect of the wound. The lens was taken from its container and inspected. No defects were found. The lens power selected was compared with the surgery worksheet from Dr. X's office. The lens was placed in an inserter under Provisc. It was placed through the wound, into the capsular bag and extruded gently from the inserter. It was noted to be adequately centered in the capsular bag using a Sinskey hook. The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique. The eye was noted to be inflated without overinflation. The wounds were tested for leaks, none were found. Five drops dilute Betadine solution was placed over the eye. The eye was irrigated. The speculum was removed. The drapes were removed. The periocular area was cleaned and dried. Maxitrol ophthalmic ointment was placed into the interpalpebral space. A semi-pressure patch and shield was placed over the eye. The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office." }

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

{ "text_length": 5105 }

{ "text": "REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam. EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation. The patient states that for the last 3 years, she has had episodes of her heart racing. It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. They subsequently resolve on their own and do not limit her in anyway. However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. She said she can walk no more than 25 feet without becoming tired. She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills. She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Myocardial infarction in 2003.,3. Left heart catheterization at University Hospital.,4. Hypercholesterolemia.,5. Arthritis.,6. CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1. Left total knee replacement in 2002.,2. Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer. There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years. She retired 7 years ago because of low back pain. She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1. Coumadin 5 mg a day.,2. Toprol-XL 50 mg a day.,3. Aspirin 81 mg a day.,4. Hydrochlorothiazide 25 mg a day.,5. Plendil 10 mg daily.,6. Lipitor 40 mg daily.,REVIEW OF SYSTEMS: ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. GENERAL: A well-developed, well-nourished, middle-aged African American female in no acute distress. NECK: Supple. No JVD. No carotid bruits. CARDIOVASCULAR: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, and nondistended. No masses. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION: ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1. Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2. We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3. We will check a thyroid function panel.,4. We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5. Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6. Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. We will await results of transthoracic echocardiogram.,7. We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period. She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology." }

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

{ "text_length": 4621 }

{ "text": "FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:, She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:, Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:, In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS: ,HEENT: For headaches and sore throat. Musculoskeletal: She is right handed with joint pain, stiffness, and decreased range of motion. Cardiac: For heart murmur. GI: Negative and noncontributory. Respiratory: Negative and noncontributory. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. Genital: Negative and noncontributory. She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall. Current weight is 132 pounds, weight one year ago was 126 pounds. BP is 122/68. On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. General, a well-developed and well-nourished female in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth good dentition. Cranial nerves II, III, IV, and VI, vision is intact, visual fields are 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 movement. Cranial nerve VIII, hearing intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. Examination of the low back reveals some mild paralumbar spasms. She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature. She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. Deep tendon reflexes are 2+ bilateral knees and ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Straight leg raising is negative bilaterally. Strength on manual exam is 5/5 and equal bilateral lower extremity. She is able to ambulate on her toes and her heels without any difficulty. She is able to get up standing on one foot on to the toes. She does have some difficulty getting up on to her heels when standing on one foot. She has trouble with this on the left and right. She complains of increased pain while doing this as well. She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left. Sensation is intact. She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout. At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. This could represent a facet synovial cyst. This is lateral to the facet. She does not have x-rays for review. She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1 Do nothing.,2. Conservative therapies.,3. Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays. We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. All questions and concerns were addressed. If she should have any further questions, concerns, or complications, she will contact our office immediately. Otherwise, we will see her as scheduled. Case was reviewed and discussed with Dr. L." }

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

{ "text_length": 5868 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:, Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1. Nasal endoscopy.,2. Partial rhinectomy.,ANESTHESIA:, General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago. He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall. He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip. He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma. The preoperative examination shows induration of the nasal tip without significant erythema. There is focal tenderness just cephalad to the alar crease. There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position. Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin. He was prepped and draped in standard fashion. The left nasal cavity was examined by anterior rhinoscopy. The septum was midline. There was slight asymmetry of the nares. No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor. The 0-degree nasal endoscope was then used to examine the nasal cavity more completely. No lesion was detectable. A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A. The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present. Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section. A diagnosis of diffuse invasive squamous cell carcinoma was rendered. An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery. The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin. The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it. Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins. Additional soft tissue was then taken from all margins tagging them for the pathologist. The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone. A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone. Additional soft tissue was taken in these regions along the superior margin. The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology. Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound. A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla. This was all submitted to pathology for routine permanent examination. Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture. The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well. Sponge and needle counts were correct." }

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

{ "text_length": 3912 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA. The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology. The patient states that this was started approximately 24 hours ago. The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain. The patient admits to poor dental hygiene. Denies any recent or dental abscesses in the past. The patient is a substance abuser, does admit to smoking cocaine approximately three days ago. The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted. After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE: ,The patient was brought in upright and supine position. Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side. This was done at the base of #18, #19, and #20 teeth. After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control. After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed. There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination. The patient understood consequences of her actions. Does state that she does not care at this time and just wants to be left alone. At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin. The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face." }

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

{ "text_length": 2736 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:, Cauterization of peri and intra-anal condylomas.,ANESTHESIA: ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week." }

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

{ "text_length": 1737 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending." }

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

{ "text_length": 3678 }

{ "text": "CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of \"swollen left foot.\" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome." }

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

{ "text_length": 3556 }

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

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

{ "text_length": 1105 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,PROCEDURE PERFORMED:,1. Insertion of a right brachial artery arterial catheter.,2. Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.,PROCEDURE:,1. RIGHT BRACHIAL ARTERIAL LINE: ,The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: ,The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes." }

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

{ "text_length": 3226 }

{ "text": "ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function." }

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

{ "text_length": 1038 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1. Repair of nerve and tendon, right ring finger.,2. Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME: ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION: ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well. The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100% transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good." }

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

{ "text_length": 3214 }

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

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

{ "text_length": 4995 }