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{ "text": "INDICATIONS:, Chest pain.,PROCEDURE DONE:, Graded exercise treadmill stress test.,STRESS ECG RESULTS:, The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate. The blood pressure increased from 120/70 to 130/80. The baseline resting electrocardiogram reveals a regular sinus rhythm. The tracing is within normal limits. Symptoms of chest pain occurred with exercise. The pain persisted during the recovery process and was aggravated by deep inspiration. Marked chest wall tenderness noted. There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1. Stress test is negative for ischemia.,2. Chest wall tenderness occurred with exercise.,3. Blood pressure response to exercise is normal." }

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

{ "text_length": 941 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed. She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement. I met with the patient's mom. With the help of a Spanish interpreter, I explained the technique for Broviac placement. We discussed the surgical risks and alternatives, most of which have been exhausted. All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION: ,The patient came to the operating room and had an uneventful induction of general anesthesia. We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter. Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath. There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. Heparinized saline solution was used to flush the line. A sterile occlusive dressing was applied, and the line was prepared for immediate use. The patient was transported to the recovery room in good condition. There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure." }

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

{ "text_length": 2826 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1. She has been dealing with these symptoms for greater than three months. She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery. I have discussed the MRI findings with the patient and the potential risks and complications. She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room. We discussed the diagnosis and the operative procedure in detail. I have reviewed the potential risks and complications and she had agreed to proceed with the surgery. Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her. She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE: ,The patient was taken to OR #5 at ABCD General Hospital. While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed. A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing. The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb. Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded. A marker was placed in from the back at this time and an x-ray was obtained for incision localization. The back is now prepped and draped in the usual sterile fashion. A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel. The lumbar dorsal fascia was then encountered and incised to the left of midline. In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule. A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space. The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination. A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina. Ligaments and fragments were encountered and removed at this time. The epidural space was now encountered. The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield. A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening. This disc fragment was removed and the nerve root was much more supple, it was carefully retracted. The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5. At this point, all disc fragments were removed from the epidural space. Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify. The disc space was now encountered and loose disc fragments were removed from within the disc space. The disc space was then irrigated. The nerve root was then reassessed and found to be quite supple. At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device. At this point, the wound was irrigated copiously and suctioned dry. Gelfoam was used to cover the epidural space. The retractors were removed at this point. The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision. The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition." }

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

{ "text_length": 4918 }

{ "text": "PROCEDURES:,1. Right frontal craniotomy with resection of right medial frontal brain tumor.,2. Stereotactic image-guided neuronavigation for resection of tumor.,3. Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE: ,The patient is a 71-year-old female with a history of left-sided weakness and headaches. She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago. An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor. After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube. She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor. We marked external landmarks. Then we shaved the head over the right medial frontal area. This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline. This was opened and hemostasis obtained using Raney clips. The skin flap was retracted medially. Two burr holes were made and were carefully connected. One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap. Hemostasis was obtained. Using the neuronavigation, we identified where the tumor was. The dura was then opened based on a horseshoe flap based on the medial sinus. We retracted this medially and carefully identified the brain. The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor. Subsequently, we entered the tumor. The tumor itself was extremely hard. Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case. We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor. Then we collapsed the tumor on itself and removed it entirely. In this fashion, microdissection and magnification resection of the tumor was carried out. We resected the entire tumor. Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam. We also lined the cavity with Surgicel. The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion. Surgicel was placed over the dural closure. The bone flap was repositioned and held in place using CranioFIX cranial fixators. The galea was re-approximated and the skin was closed with staples. The wound was dressed. The patient was returned to the intensive care unit. She was awake and moving extremities well. No apparent complications were noted. Needle and sponge counts were listed as correct at the end of the procedure. Estimated intraoperative blood loss was approximately 150 mL and none was replaced." }

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

{ "text_length": 4117 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS: ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE: ,Right eye was prepped and draped in the normal sterile fashion. Lid speculum placed in his right eye. Paracentesis made supratemporally. Viscoat injected into the anterior chamber. A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally. This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed. Nuclear material removed via phacoemulsification. Residual cortex removed via irrigation and aspiration. The posterior capsule was clear and intact. Capsular bag was then filled with Provisc solution. The wound was enlarged to 3.5 mm with the keratoma. The lens was folded in place into the capsular bag. Residual Provisc was irrigated from the eye. The wound was secured with one 10-0 nylon suture. The lid speculum was removed. One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment. He had a patch placed on it. The patient was transported to the recovery room in stable condition." }

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

{ "text_length": 1369 }

{ "text": "PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:, None.,INJECTABLES:, Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:, Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s)." }

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

{ "text_length": 2261 }

{ "text": "PREPROCEDURE DIAGNOSIS:, Left leg claudication.,POSTPROCEDURE DIAGNOSIS: , Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE: ,The patient presents with lower extremity claudication. She is a 68-year-old woman, who is very fearful of the aforementioned procedures. Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence. She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position. After adequate conscious sedation, both groins were prepped with Chloraseptic prep. Cloth towels and paper drapes were placed. Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed. Guidewire was threaded followed by a ,4-French sheath. Through the 4-French sheath a 4-French Omni flush catheter was placed. The glidewire was removed and contrast administered to identify the level of the renal artery. Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation. A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach. The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery. The Omni flush catheter was advanced to the left distal external iliac artery. The glidewire rather exchanged for an Amplatz stiff wire. This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath. This was advanced into the proximal superficial femoral artery and an angiogram performed. I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate. A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels. A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection. A search for a 5-mm stent was performed, but none of this was available. For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery. Post dilatation was performed with a 4-mm angioplasty balloon. Further views of the left lower extremity showed irregular change in the popliteal artery. No significant stenosis could be identified in the left popliteal artery and noninvasive scan. For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device. Attention was turned to the left femoral artery and local anesthesia administered. Access was obtained with the ultrasound and the femoral artery identified. Guidewire was threaded followed by a 4-French sheath. This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery. The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath. The destination was placed in the proximal superficial femoral artery and angiogram obtained. Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery. For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon. A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation. No further significant abnormality was identified. To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery. A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis. Reasonable use were obtained and possibly a 4-mm balloon could have been used. However, due to her propensity for dissection I opted not to. I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length. This was placed into the left posterior tibial artery. A 2-mm balloon was used to dilate the orifice of the posterior tibial artery. I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel. Final images showed improved run-off to the right calf. The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma. No evidence of renal artery stenosis is noted bilaterally. There is a single left renal artery. The infrarenal aorta, both common iliac and the external iliac arteries are normal. On the right, a superficial femoral artery is widely patent and normal proximally. At the distal third of the thigh there is diffuse disease with moderate stenosis noted. Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted. The perineal artery is functionally occluded at the midcalf. The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent. Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery. This was successfully treated with angioplasty and a stent placement. The popliteal artery is diffusely diseased without focal stenosis. The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1. Normal bilateral renal arteries with a small accessory right renal artery.,2. Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3. The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries. Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4. Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement. Run-off to the left lower extremity is via a patent perineal and posterior tibial artery." }

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

{ "text_length": 6830 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,OPERATION PERFORMED:, Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place. The skin was prepped and draped in a sterile classical fashion. The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter. The patient was given oxygen, intravenous sedation and analgesics as needed. The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's \"Scottie dog\" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets. A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique. After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule. After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet. The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted." }

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

{ "text_length": 1582 }

{ "text": "EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle." }

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

{ "text_length": 2550 }

{ "text": "PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted." }

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

{ "text_length": 8334 }

{ "text": "HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease. The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall. The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:, As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss. No history of sore throat. No history of any ascites. No history of nausea, vomiting, or diarrhea. No black stools. No history of any rash. No back pain. No leg pain. No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:, He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT: The patient is atraumatic and normocephalic. Pupils are equal and reactive to light. Extraocular muscles are intact.,NECK: Supple. No JVD and no thyromegaly.,HEART: S1 and S2 heard. No murmurs or extra sounds.,ABDOMEN: Distention of the abdomen present.,EXTREMITIES: No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34. PT, PTT, and INR is normal. Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's. Potassium is 5.3, BUN of 39, and creatinine of 1.9. Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN: ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis. The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy. We will do urine for cytology. We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels. We will send a PSA level and if needed may be a urology consult." }

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

{ "text_length": 2796 }

{ "text": "PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:, This is a 42-year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient's increasing pain, surgery is recommended. The alternatives, risks and benefits of surgery were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives to surgery. The patient wished to proceed with operative intervention. A signed and witnessed informed consent was placed on the chart. Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:, Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1. There was a medium-sized (5 - 10 mm) anterior acromial spur.,2. The subacromial bursa was inflamed.,3. The subacromial bursa was thickened.,4. There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. Muscles and Tendons: The biceps tendon is within normal limits.,JOINT:, Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. All body parts were well padded and protected to make sure there were no pressure points. Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1. Scope Ports: Anterior Portal.,2. Scope Ports: Posterior Portal.,3. Scope Ports: Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1. The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2. The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3. The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4. The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. Approximately 5 mm of bone was removed. The coracoacromial ligament was released with the bony resection. The shoulder joint was thoroughly irrigated.,5. The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6. The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7. The repair was stable to palpation with the probe and watertight.,8. The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:, The joint was thoroughly irrigated with 7 L of sterile saline. The portal sites were infiltrated with 1% Xylocaine. The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:, Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:, Final counts were correct." }

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

{ "text_length": 4025 }

{ "text": "DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1." }

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

{ "text_length": 126 }

{ "text": "HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8." }

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

{ "text_length": 1024 }

{ "text": "CERVICAL FACET JOINT INJECTION WITH CONTRAST.,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. the patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was used. For further details of IV sedation and infusion, please refer to anesthesia notes. Fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints. The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:, The patient was laid supine. Appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head. The neck was aseptically prepared. 1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C4-5 facet joint under fluoroscopic control. Positioning was checked and 0.2 mL of dye was injected. Acceptable dye pattern was seen. Subsequent 1 mL of a mixture of 0.5 mL of 1% lidocaine and 0.5 mL of Celestone was injected after aspiration and the patient was monitored. Needle was removed and same procedure carried out on the other side. Postprocedure, no complications were noted." }

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

{ "text_length": 1317 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,PROCEDURE PERFORMED:,1. Evacuation of epidural hematoma.,2. Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,200 cc.,HISTORY: ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction. She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess. The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change. The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement. Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing. When she examined the patient, she also noted that the patient was unable to move her extremities. She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic. I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma. On clinical examination, there was swelling in the posterior aspect of the neck. The patient has no active movement in the upper and lower extremity muscle groups. Reflexes are absent in the upper and lower extremities. Long track signs are absent. Sensory level is at the C4 dermatome. Rectal tone is absent. I discussed the findings with the patient and also the daughter. We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery. They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE: ,The patient was taken to OR #1 at ABCD General Hospital on a gurney. Department of Anesthesia administered fiberoptic intubation and general anesthetic. A Foley catheter was placed in the bladder. The patient was log rolled in a prone position on the Jackson table. Bony prominences were well padded. The patient's head was placed in the prone view anesthesia head holder. At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound. Next, the patient was prepped and draped in the usual sterile fashion. The previous skin incision was reopened. At this point, hematoma properly exits from the wound. All sutures were removed and the epidural spaces were encountered at this time. The self-retaining retractors were placed in the depth of the wound. Consolidated hematoma was now removed from the wound. Next, the epidural space was encountered. There was no additional hematoma in the epidural space or on the thecal sac. A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac. The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well. Next, the wound was irrigated copiously with one liter of saline using a syringe. The walls of the wound were explored. There was no active bleeding. Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding. A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space. Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures. Steri-Strips covered the incision and dressing was then applied over the incision. The patient was then log rolled in the supine position on the hospital gurney. She remained intubated for airway precautions and transferred to the recovery room in stable condition. Once in the recovery room, she was alert. She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities. Prognosis for this patient is guarded." }

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

{ "text_length": 5250 }

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

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

{ "text_length": 5464 }

{ "text": "PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. The preparation was excellent and all surfaces were well seen. The hypopharynx appeared normal. The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. This appears to be consistent with Barrett esophagus. Multiple biopsies were taken from numerous areas in this region. There was no active ulceration or inflammation and no stricture. The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. The gastric body had normal mucosa throughout. Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. Biopsies were taken from the antrum to rule out Helicobacter pylori. A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. The scope was passed through the pylorus, which was patent and normal. The mucosa throughout the duodenum in the first, second, and third portions was entirely normal. The scope was withdrawn and the patient was sent to the recovery room. He tolerated the procedure well.,FINAL DIAGNOSES:,1. A short-segment Barrett esophagus.,2. Hiatal hernia.,3. Incidental fundic gland polyps in the gastric body.,4. Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1. Follow up biopsy report.,2. Continue PPI therapy.,3. Follow up with Dr. X as needed.,4. Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis)." }

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

{ "text_length": 2063 }

{ "text": "XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely," }

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

{ "text_length": 3100 }

{ "text": "TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06. The patient was recorded digitally using the 10-20 system of electrode placement. Additional temporal electrodes and single channels of EOG and EKG were also recorded. The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated. Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION: ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:, There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event. The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. At 1:38 p.m., the patient was instructed to begin hyperventilation. Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. When asked what had just occurred, she replied that she was asleep and did not remember any event. When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event. Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:, The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation. No epileptiform activity is present. One clinical event was induced with hyperventilation and photic stimulation. The clinical features of this event are described in the technical summary above. There was no epileptiform activity associated with this event. This finding is consistent with a non-epileptic pseudoseizure." }

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

{ "text_length": 2667 }

{ "text": "FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia." }

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

{ "text_length": 2310 }

{ "text": "HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services." }

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

{ "text_length": 3014 }

{ "text": "CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission. The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting. The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction. The patient was subsequently admitted for possible obstruction. The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.) He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily. Esophageal reflux treated with Nexium 40 mg daily. Allergic rhinitis treated with Allegra 180 mg daily. Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly. Glaucoma treated with Xalatan drops. History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES: ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of \"old age,\" mother died at age 89 of \"old age.\" Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY: ,The patient is widowed and a retired engineer. He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss. HEENT: Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat. Neck: Denies neck stiffness, no pain or masses in the neck. Respiratory: Denies cough, sputum production, hemoptysis, wheezing or shortness of breath. Cardiovascular: Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation. Gastrointestinal: See history of the present illness. Urinary: Denies dysuria, frequency, urgency or hematuria. Neuro: Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL: The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT: Atraumatic, normocephalic. Eyes, EOMs full, PERRLA. Fundi benign. TMs normal. Nose clear. Throat benign.,NECK: Supple with no adenopathy. Carotid upstrokes normal with no bruits. Thyroid is not enlarged.,LUNGS: Clear to percussion and auscultation.,HEART: Regular rate, normal S1 and S2 with no murmurs or gallops. PMI is nondisplaced.,ABDOMEN: Mildly distended with mild diffuse tenderness. There is no rebound or guarding. Bowel sounds are hypoactive.,EXTREMITIES: No cyanosis, clubbing or edema. Pulses are strong and intact throughout.,GENITALIA: Atrophic male, no scrotal masses or tenderness. Testicles are atrophic. No hernia is noted.,RECTAL: Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:, WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000. Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44. Alkaline phosphatase, AST and ALT are all normal. UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1. Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2. Hypertension.,3. Esophageal reflux.,4. Allergic rhinitis.,5. Glaucoma.,PLAN: , The patient is admitted to the medical floor. He has been kept NPO and will be given IV fluids. He will also be given antiemetic medications with Zofran and an analgesic as necessary. General surgery consultation was obtained. Abdominal series x-ray will be done." }

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

{ "text_length": 4512 }

{ "text": "SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:, The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.,PLAN:, The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005." }

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

{ "text_length": 895 }

{ "text": "CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of \"dystonia.\",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild \"ataxia\" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993." }

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

{ "text_length": 2574 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck. The patient demonstrates the deformities described above and has requested surgical correction. The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient. The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started and anesthesia was maintained throughout the case. The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line. A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline. In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift. The incision was marked in the submental crease for the submental lipectomy and liposuction. The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine. This provided local anesthesia and vasoconstriction. The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery. A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible. 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly. The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels. Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area. A similar procedure was performed with the 4 mm cannula cleaning the area. Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle. A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion. 5-0 plain catgut was used for closure in a running interlocking fashion. The wound was cleaned at the end, dried, and Mastisol applied. Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal. A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region. A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin. The incision was made in the temporal area beveling parallel with the hair follicles. (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid. The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim. At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible. This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl. Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS. The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region. When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected. At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM. The SMAS flap was then advanced posteriorly and superiorly. The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum. The excess SMAS was trimmed and excised from the portion anterior to the auricle. The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained. The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture. The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period. Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area. The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion. 5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing. The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut. The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation. Any small amount of fluid was expressed post-auricularly. A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure. A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas. This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion. The entire dressing complex was secured with a pre-formed elastic stretch wrap device. All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition." }

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

{ "text_length": 8540 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Suspicious microcalcifications, left breast.,POSTOPERATIVE DIAGNOSIS:, Suspicious microcalcifications, left breast.,PROCEDURE PERFORMED:, Needle-localized excisional biopsy, left breast.,ANESTHESIA:, Local with sedation.,SPECIMEN: ,Left breast with specimen mammogram.,COMPLICATIONS:, None.,HISTORY: , The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast. She had no palpable mass on physical exam. She does have significant family history with two daughters having breast cancer. The patient also has a history of colon cancer. A surgical biopsy was recommended and she was scheduled electively.,PROCEDURE:, After proper informed consent was obtained, she was placed in the operative suite. This occurred after undergoing preoperative needle localization. She was placed in the operating room in the supine position. She was given sedation by the Anesthesia Department. The left breast was prepped and draped in the usual sterile fashion. The skin was infiltrated with local and a curvilinear incision was made in the left lower outer quadrant. The breast tissue was grasped with Allis clamps and a core of tissue was removed around the localization wire. There were some fibrocystic changes noted. The specimen was then completely removed and was sent to Radiology for mammogram. The calcifications were seen in specimen per Dr. X. Meticulous hemostasis was achieved with electrocautery. The area was irrigated and suctioned.,The aspirant was clear. The skin was then reapproximated using #4-0 undyed Vicryl in a running subcuticular fashion. Steri-Strips and sterile dressing on the patient's bra were applied. The patient tolerated the procedure well and was transferred to recovery room in stable condition." }

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

{ "text_length": 1849 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:, Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA: ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology. The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded. Tourniquet was placed around the left upper thigh. The limb was then prepped and draped in usual sterile fashion. Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed. Patellofemoral joint showed frequent chondromalacia. Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus. The medial femoral condyle and medial tibial plateau were unaffected. Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus. The femoral condyle and tibial plateau were all stable to probing. Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors. A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry. 20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals. A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose. The patient was then transferred to the recovery room in stable condition." }

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

{ "text_length": 1964 }

{ "text": "ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Fibroid uterus.,OPERATIONS PERFORMED:,1. Hysteroscopy.,2. Dilatation and curettage (D&C).,3. Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed. Hysteroscopy revealed a large endometrial cavity fibroid. Careful shaving and excision of this fibroid was performed with removal of the fibroid. Hemostasis was noted completely at the end of this procedure. Postoperatively, the patient has done well. The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss. The patient is now ambulating without difficulty and tolerating her diet. The patient desires to go home. The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS: ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks. Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate tablets 1 tablet p.o. daily. Ambulate with assistance at home only. The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care. The patient was given full and complete postop and discharge instructions. All her questions were answered." }

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

{ "text_length": 1842 }

{ "text": "2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures." }

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

{ "text_length": 662 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the 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 belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed." }

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

{ "text_length": 5263 }

{ "text": "DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition." }

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

{ "text_length": 667 }

{ "text": "CHIEF COMPLAINT: ,Hip pain.,HISTORY OF PRESENTING ILLNESS: ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office. She reports moderate to severe pain related to a complicated past medical history. In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23. She was given nonsteroidals at that time, which did help with this discomfort. With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital. She was referred for rehabilitation and strengthening. Most of this was focused on her SI joints. At that time, although she had complained of foot discomfort, she was not treated for it. This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996. She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain. She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back. Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B. She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case. Subsequently, nuclear bone scans revealed osteoarthritis. Orthotics were provided. She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure. During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle. She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since. She currently does not have an established cardiologist having just changed insurance plans. She is establishing care with Dr. S, of Rheumatology for her ongoing care. Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis. A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation. She then transferred her care to Ab Cd, FNP under the direction of Dr. K. Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens. Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY: ,1. Attention deficit disorder.,2. TMJ arthropathy.,3. Migraines.,4. Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1. Cystectomies.,2. Sinuses.,3. Left ganglia of the head and subdermally in various locations.,4. TMJ and bruxism.,FAMILY HISTORY: ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1. Methadone 2.5 mg p.o. t.i.d.,2. Norco 10/325 mg p.o. q.i.d.,3. Tenormin 50 mg q.a.m.,4. Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5. Wellbutrin SR 100 mg q.d.,6. Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives. Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS: Blood pressure 110/72 with a pulse of 68.,HEENT: Normocephalic. Atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular motions are intact. No scleral icterus. No nystagmus. Tongue is midline. Mucous membranes are moist without exudate.,NECK: Free range of motion without thyromegaly.,CHEST: Clear to auscultation without wheeze or rhonchi.,HEART: Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN: Soft, nontender.,MUSCULOSKELETAL: There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally. Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side. Toe-heel walking is performed without difficulty. Straight leg raises are negative. Romberg's are negative.,NEUROLOGIC: Grossly intact. Intact reflexes in all extremities tested. Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review. I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage." }

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

{ "text_length": 5589 }

{ "text": "SUBJECTIVE:, The patient is in with several medical problems. He complains his mouth being sore since last week and also some \"trouble with my eyes.\" He states that they feel \"funny\" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same.,CURRENT MEDICATIONS:, Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General: He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs: His age is 66. Temperature: 97.7. Blood pressure: 134/80. Pulse: 88. Weight: 201 pounds.,HEENT: Head was normocephalic. Examination of the throat reveals it to be clear. He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm.,Extremities: He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder. Back has limited range of motion. He is nontender to his back. Deep tendon reflexes are 2+ bilaterally in lower extremities. Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen: Soft, nontender without hepatosplenomegaly or mass. He has normal bowel sounds.,ASSESSMENT:,1. Clostridium difficile enteritis, improved.,2. Right shoulder pain.,3. Chronic low back pain.,4. Yeast thrush.,5. Coronary artery disease.,6. Urinary retention, which is doing better.,PLAN:, I put him on Diflucan 200 mg daily for seven days. We will have him stop his metronidazole little earlier at his request. He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course. I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.) Recheck with me in two to three weeks." }

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

{ "text_length": 2644 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:, Local with monitored anesthesia care.,INDICATIONS:, Patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. The deep margin was positive. Other margins were clear. He was brought back for re-excision.,PROCEDURE:, The patient was brought to the operating room and placed in the supine position. He was given intravenous sedation. The right hand was prepped and draped in the usual sterile fashion. Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline. Hemostasis was assured with the electrocautery. The wound was closed with running 3-0 nylon without complication. The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied." }

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

{ "text_length": 1358 }

{ "text": "PROCEDURE:, Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained. Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL: ,The patient was placed in the left lateral decubitus position. Medications were given. After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum." }

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

{ "text_length": 878 }

{ "text": "CHIEF COMPLAINT:,1. Metastatic breast cancer.,2. Enrolled is clinical trial C40502.,3. Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502. She was randomized to the ixabepilone plus Avastin. She experienced dose-limiting toxicity with the fourth cycle. The Ixempra was skipped on day 1 and day 8. She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. Early in the month she had concerned about possible perforated septum. She was seen by ENT urgently. She was found to have nasal septum intact. She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS: ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES: ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation. She has progressive neuropathy and decreased sensation in her fingertips. She makes many errors when keyboarding. I would rate her neuropathy as grade 2. She continues to have headaches respond to Ultram which she takes as needed. She occasionally reports pain in her right upper quadrant as well as right sternum. He denies any fevers, chills, or night sweats. Her diarrhea has finally resolved and her bowels are back to normal. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:" }

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

{ "text_length": 1905 }

{ "text": "CC:, Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:, None.,ROS: , As above. Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS. He is in no apparent distress. ,Vital Signs: BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT: No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness. ,Neck: Nontender ,Chest: Breathing comfortably; equal breath sounds. ,Heart: Regular rhythm.,Abd: Benign.,Ext: No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro: Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal. ,COURSE IN THE ED:, Patient arrived and was placed on monitors. An IV had been placed in the field and labs were drawn. X-rays of the C spine show no fracture and I've removed the C-collar. The lacerations were explored and no foreign body found. They were irrigated and closed with simple interrupted sutures. Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine. The blood alcohol returned at 0.146. A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care." }

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

{ "text_length": 1844 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself." }

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

{ "text_length": 2052 }

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

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

{ "text_length": 2960 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. He did not have any apnea during this episode.,PAST MEDICAL HISTORY:, Unremarkable. He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL: Sleeping, easily aroused, smiling, and in no distress.,HEENT: Soft anterior fontanelle. TMs are normal. Moist mucous membranes.,LUNGS: Equal and clear.,CHEST: Without retraction.,HEART: Regular in rate and rhythm without murmur.,ABDOMEN: Benign.,DIAGNOSTIC STUDIES:, Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:, Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares. Smaller but more frequent feeds. Discuss proper sleeping position. Recheck if there is any fever or if he is no better in the next three days." }

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

{ "text_length": 1359 }

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

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

{ "text_length": 2849 }

{ "text": "PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal. No evidence of friability, ulceration or tumor mass was encountered. The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed." }

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

{ "text_length": 702 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition." }

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

{ "text_length": 1758 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1. Medial meniscal tear, right knee.,2. Lateral meniscal tear, right knee.,3. Osteochondral lesion, medial femoral condyle, right knee.,4. Degenerative joint disease, right knee.,5. Patella grade-II chondromalacia.,6. Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1. Arthroscopy, right knee.,2. Medial meniscoplasty, right knee.,3. Lateral meniscoplasty, right knee.,4. Medial femoral chondroplasty, right knee.,5. Medical femoral microfracture, right knee.,6. Patellar chondroplasty.,7. Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:, The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position. Department of Anesthesia administered general anesthetic. Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder. Care was ensured that all bony prominences were well padded and she was positioned and secured. After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion. Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively. The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch. All compartments were then examined in sequential order with photodocumentation of each compartment. The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove. There was mild grooving of the trochlear cartilage. The medial gutter was visualized. There was no evidence of loose body. The medial compartment was then entered. There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment. There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus. The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken. At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed. This gave a smooth shoulder to the chondral lesion. After this, the meniscus was debrided until it had been smooth over the frayed edges. At this point, the shaver was removed. The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point. The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge. The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable. At this point, attention was directed to the rest of the knee. The ACL was examined. It was intact and stable. The lateral compartment was then entered. There was noted to be a grade II-III changes of the lateral femoral condyle. Again, with the edge of some friability at the shoulder of this cartilage lesion. There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus. The probe was introduced and the remaining meniscus appeared stable. This was then removed and the stapler was introduced. A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over. The lateral gutter was then visualized. There was no evidence of loose bodies. Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion. Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion. After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided. At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided. Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies. The knee was then copiously irrigated and suctioned dry. All instrumentation was removed. Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular. Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied. The patient was then transferred back to the gurney in supine position.,DISPOSITION: The patient tolerated the procedure well with no complications. The patient was transferred to PACU in satisfactory condition." }

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

{ "text_length": 5373 }

{ "text": "CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy." }

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

{ "text_length": 3505 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:, Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:, Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout." }

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

{ "text_length": 5773 }

{ "text": "PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope. He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture. He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass. His mandible fracture was not noted initially. The patient also has a history of prostate cancer and a renal cell carcinoma. The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending. The patient later saw a local oral surgeon. He diagnosed his mandible fracture and advised him to seek treatment in Houston. He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago. The patient had significant discomfort and could eat foods and drink fluids with difficulty. Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position. Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion. The patient was then prepped and draped in a manner consistent with sterile procedures. A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible. A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue. A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible. Electrocautery as well as 4.0 silk ties were used for hemostasis. A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site. The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound. Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis. Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site. Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site. When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically. All the screws were also locking screws. Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline. The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin. A sterile dressing was then placed over the incision. The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs. Estimated blood loss is 125 mL." }

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

{ "text_length": 4492 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2. Bone grafts.,3. Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:, None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis. We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft. We have discussed risks and benefits. Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection. The parents understand, decide to proceed with surgery. Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. Prophylactic dose of antibiotic was given. Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees. The patient was once more positioned and padded in the usual manner. The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane. The subgaleal plane was developed and reflected anteriorly and slightly posteriorly. Hemostasis achieved with electrocautery. Raney clips were applied to both flaps to prevent significant bleeding. Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure. I assisted her and this will be described in a different operative report. Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor. The osteotomies were done with the Midas and some irrigation. There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim. This was done on both sides. Hemostasis achieved with bone wax and electrocautery. Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements. On the left side, there was a minor fracture to the superior orbital rim that was plated. The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim. The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches. The forehead flaps were attached with the help of absorbable mesh. The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws. Hemostasis was checked. The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut. Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net. The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure." }

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

{ "text_length": 4267 }

{ "text": "SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet." }

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

{ "text_length": 1839 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:, Left medial compartment osteoarthritis of the knee.,PROCEDURE PERFORMED:, Left unicompartmental knee replacement.,COMPONENTS USED:, Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:, None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side. She has done quite well with this. She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table. After appropriate anesthesia, the left lower extremity was identified with a time out procedure. Preoperative antibiotics were given. Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. The anterior fat pad was removed. The knee was then examined. The ACL was found to be intact. The lateral compartment had very minimal arthritis. There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. Following this resection, the femoral intramedullary guide was placed without difficulty. The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. Once in the appropriate position, it was pinned and drilled. This was removed, and the posterior cutting block was inserted. It was impacted into place. Posterior bone cut was made for the medium femoral component. Next, a zero spigot was used and the distal femur was reamed. Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. Next, the tibia was prepared. The tibial tray was pinned into place, and the cuts for the keel of the tibia were made. These were removed with a small osteotome from the set. Following this, a trial tibial with the keel was placed and it did fit nicely. After this, all trial components were removed. The knee was copiously irrigated. Cement was begun mixing. Drill holes were used along the femur for cement interdigitation. The wound was cleaned and dried. Cement was placed on the tibia. Tibial tray was impacted into place. Excess cement was removed. Tibia was placed in the femur. Femoral component was impacted into place. Excess cement was removed. It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. The intramedullary rod removed from the femur. The wound was irrigated with normal saline. The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin. A sterile dressing was placed. Tourniquet was then desufflated. Sponge and needle counts were correct at the end of the procedure. Dr. Jinnah was present for the surgery. The patient was transferred to the recovery room in stable condition. She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis. Prior to closure, the posterior capsule was injected with the joint cocktail." }

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

{ "text_length": 4414 }

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

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

{ "text_length": 12779 }

{ "text": "S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis.," }

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

{ "text_length": 645 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:, Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion. Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid. A frontal nerve block was also given on the right upper lid. The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect. The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly. The specimen was then marked and sent to pathology for frozen section. Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid. The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis. Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly. It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region. The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures. The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied. The patient tolerated the procedure well and was sent to recovery room in good condition." }

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

{ "text_length": 2646 }

{ "text": "SUBJECTIVE:, The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has noticed a few more bruises on her legs. No fever or chills with slight cough. She has had more chest pains but not at present. She does have a little bit of nausea but no vomiting or diarrhea. She complains of some left shoulder tenderness and discomfort. She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:, She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General: She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs: Her age is 55. Temperature: 98.2. Blood pressure: 110/70. Pulse: 72. Weight: 174 pounds.,HEENT: Head was normocephalic. Throat: Clear. TMs clear.,Neck: Supple without adenopathy.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender without hepatosplenomegaly or mass.,Extremities: Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted. Her shoulders have full range of motion. She has minimal tenderness to the left shoulder anteriorly.,Skin: There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1. Headaches.,2. Dizziness.,3. Atypical chest pains.,4. Chronic renal failure.,5. Type II diabetes.,6. Myalgias.,7. Severe anxiety (affect is still quite anxious.),PLAN:, I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m. I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin. Recheck in one week. I think her dizziness is multifactorial and due to enlarged part of her anxiety. I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin." }

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

{ "text_length": 2590 }

{ "text": "HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy. I told her that the interval was appropriate and that it made sense to do so. She denies any significant weight change that she cannot explain. She has had no hematochezia. She denies any melena. She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:, On today's visit we reviewed her entire health history. Surgically she has had a stomach operation for ulcer disease back in 1974, she says. She does not know exactly what was done. It was done at a hospital in California which she says no longer exists. This makes it difficult to find out exactly what she had done. She also had her gallbladder and appendix taken out in the 1970s at the same hospital. Medically she has no significant problems and no true medical illnesses. She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day. She was counseled to quit. She occasionally uses alcohol. She has never used illicit drugs. She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL: A is a healthy appearing female in no apparent distress.,VITAL SIGNS: Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT: No cervical bruits, thyromegaly, or masses. She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS: Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART: Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO: No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy. We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers. She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well. I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience." }

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

{ "text_length": 3057 }

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

{ "text_length": 2044 }

{ "text": "REASON FOR FOLLOWUP:, Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes. Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well. Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary. As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done. However, last night the patient had apparently catastrophic event around 2:40 in the morning. Rapid response was called and the patient was intubated, started on pressure support, and given CPR. This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care. The patient was seen and examined, she was intubated and sedated. Limbs were cool. Cardiovascular exam revealed tachycardia. Lungs had coarse breath sounds. Abdomen was soft. Extremities were cool to the touch. Pupils were 6 to 2 mm, doll's eyes were not intact. They were not responsive to light. Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures. All pressure support was discontinued. The patient was started on intravenous morphine and respiratory was requested to remove the ET tube. Monitors were turned off and the patient was made as comfortable as possible. Family is at the bedside at this time. The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes." }

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

{ "text_length": 2717 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1. Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,3. Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005. During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in. He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event. The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time. In that interval, he had a coronary artery bypass graft and was taken off of Plavix. Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated. I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer. We could not identify the right ureteral orifice, and he had a right ureteral stent placed. Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy. He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier. Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS: ,On exploration, there were multiple abnormalities outside the bladder as follows: There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface. There were two much smaller lesions also with a small white scar, with very little palpable mass. The larger of the two was resected and found to be a carcinoid tumor. There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes. The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined. There was a frozen section of the distal right external iliac lymph node that was negative. The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface. The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures. The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that. The rest of the large bowel appeared normal. There were no masses in the liver, and the gallbladder was surgically absent. There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion. The radiologist placed a radial arterial line and an intravenous catheter. Intravenous antibiotics were given for prophylaxis. We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline. Exploration was carried out with the findings described. The bladder was adherent and did appear immobile. Moist wound towels and a Bookwalter retractor was placed for exposure. We began by assessing the small and large bowel with the findings in the small bowel as described. We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture. We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum. The ureters were carefully dissected out and down deep in the true pelvis. The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber. I kept the ureters intact until we were moving the bladder off as described above. At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes. The common iliac lymph nodes remained stuck to the ureter. Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally. I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels. Clips were used to control the lymphatics distally. These lymph nodes were sent for frozen section, which was negative. We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it. The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those. On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down. I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate. At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally. The endopelvic fascia was incised. I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia. I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically. I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch. I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra. I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field. The bivalved prostate appeared normal. We then carefully inspected the rectal wall and noted to be intact. The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic \"pop,\" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant. Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia. Interrupted stitches were placed as well. The subcutaneous tissue was irrigated and skin closed with surgical clips. The estimated blood loss was 2500 mL. The patient received 5 units of packed red blood cells and 4 units of FFP. The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition." }

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

{ "text_length": 12574 }

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

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

{ "text_length": 2505 }

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

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

{ "text_length": 3386 }

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

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

{ "text_length": 3661 }

{ "text": "FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified. " }

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

{ "text_length": 10646 }

{ "text": "EXAM:, Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:, Chest pain.,TYPE OF TEST: ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76. EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.,SUMMARY:,1. Nondiagnostic Lexiscan.,2. Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:, Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 41% by gated SPECT." }

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

{ "text_length": 1169 }

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

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

{ "text_length": 3568 }

{ "text": "CHIEF COMPLAINT:, Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:, A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema.,She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.,PAST MEDICAL HISTORY:, Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:, She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis.,SOCIAL HISTORY:, The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.,MEDICATIONS:, Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:, As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General: No fever, chills, or night sweats. Weight stable.,HEENT: No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions.,Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well.,Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years.,GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge.,Musculoskeletal: As above.,Hematological: She has had some anemia in the past.,Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal.,Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present.,Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present.,Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally.,Abdomen: Obese, soft with no hepatosplenomegaly or masses.,Breasts: No predominant masses, discharge, or asymmetry.,Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema.,Lymph nodes: No cervical, axillary, or inguinal adenopathy.,Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally.,LABORATORY: ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely.,2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear.,3. Diabetes mellitus type II, really fairly well controlled." }

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

{ "text_length": 6083 }

{ "text": "EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding. ,LIPS/TEETH/GUMS: ,The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection. ,OROPHARYNX: ,The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway." }

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

{ "text_length": 1310 }

{ "text": "CHIEF COMPLAINT:, The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:, The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:, Compazine and Allegra.,OBJECTIVE:,Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27.,PLAN:, We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out.,PROCEDURE:,: She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen." }

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

{ "text_length": 3658 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:, Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:, Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:, General ,ESTIMATED BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS:, None.,DESCRIPTION OF FINDINGS:, The patient consented to revision surgery because of the profound hearing loss in her right ear. It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate. She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis. There was no incus. There was no specific round window niche. There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane. The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operative room and placed in supine position. The right face, ear, and neck prepped with ***** alcohol solution. The right ear was draped in the sterile field. External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine. A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position. Meatal skin was elevated, middle ear was entered. This exposure included the oval window, round window areas. There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum. The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate. The prosthesis was removed without difficulty. The patient's stapes had an arch, but the ***** was atrophied. Malleus handle was mobile. The footplate was fixed. Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane. The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation. She is not considered to be a reconstruction candidate under the current circumstances. No attempt was made to remove bone from the round window area. A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate. The fit was secure and supported with Gelfoam in the middle ear. The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex. The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied." }

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

{ "text_length": 3019 }

{ "text": "CHIEF COMPLAINT:, \"Trouble breathing.\",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:, Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage.,PAST SURGICAL HISTORY:, IVC filter placement 1999." }

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

{ "text_length": 1955 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.,Details Of Procedure: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach. Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia. The foot was then prepped and draped in the usual sterile orthopedic fashion. An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge. Attention was then directed to the plantar medial aspect of the left heel. An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed." }

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

{ "text_length": 3101 }

{ "text": "PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder." }

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

{ "text_length": 1068 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,PROCEDURES:, ,1. Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2. Placement of antibiotic-impregnated beads.,ANESTHESIA:, General.,BLOOD LOSS:, Minimal.,COMPLICATIONS:, None.,FINDINGS:, Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:, After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion. The tourniquet was inflated and the previous wound was opened. Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound. The wound margins were healthy with the exception of very central triangular incision area. The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension. The soft dressing was placed. An Ace was placed. She was awakened from the anesthesia and taken to recovery room in a stable condition. Final needle, instrument, and sponge counts were correct." }

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

{ "text_length": 1469 }

{ "text": "OPERATIONS,1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3. Posterior leaflet abscess resection.,ANESTHESIA: ,General endotracheal anesthesia,TIMES: ,Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition." }

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

{ "text_length": 5851 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Injury to the adjacent viscera.,6. Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty. The patient was shaved, prepped, and draped using the usual sterile technique. A sterile 16-French Foley catheter was then placed with clear urine drained. A midline infraumbilical incision was performed by using a #10 scalpel blade. The rectus fascia and the subcutaneous space were opened by using the Bovie. Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. A Bookwalter retractor was then placed. The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors. Opening was enlarged by using sharp dissection. Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion. With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie. Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors. The urethra could then be easily identified. Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors. This exposed the blue Foley catheter. Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture. Six of these were placed evenly spaced out anteriorly to posteriorly. The Foley catheter was then removed. This allowed for better traction of the prostate laterally. Lateral pelvic fascia was opened bilaterally. This effectively released the neurovascular bundle from the apex to the base of the prostate. Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. The prostate was then dissected from laterally to medially from this opening in the perirectal fat. The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. Maximal length of ureteral stump was preserved. The prostate was carefully lifted cephalad by using gentle traction with fine forceps. The prostate was easily dissected off the perirectal fat using sharp dissection only. Absolutely, no traction to the neurovascular bundle was evident at any point in time. The dissection was carried out easily until the seminal vesicles could be visualized. The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. The bladder neck was then dissected out by using a bladder neck dissection method. Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. This was developed without any difficulty. Both vas deferens were identified, hemoclipped and transected. The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. About two-thirds of the seminal vesicles were able to be removed. The tip was left behind. Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. This was performed on the left side and then the right side. This completely freed the prostate. The prostate was sent for permanent section. The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures. The mucosa of the bladder neck was everted by using 4-0 chromic sutures. Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. This was performed by using a French ***** needle. A 20-French Foley catheter was then inserted and the sutures were sequentially tied down. A 15 mL of sterile water was inflated to balloon. The bladder anastomosis to the urethra was performed without any difficulty. A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region. All instrument counts, lap counts, and latex were verified twice prior to the closure. The rectus fascia was closed in running fashion using #1 PDS. Subcutaneous space was closed by using 2-0 Vicryl sutures. The skin was reapproximated by using metallic clips. The patient tolerated the procedure well and was transferred to the recovery room in stable condition." }

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

{ "text_length": 6170 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:, General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition." }

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

{ "text_length": 3076 }

{ "text": "IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr. Circumstances leading to this admission: In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h. Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper. ABCD is also complaining of headaches when he takes the medication. Mother reports that on the weekends he is off the medication. She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, \"It's an accident.\" She sees him as impulsive on the weekends, but is not sure if this just isn't \"all boy.\",Mother reports ABCD has been on medication since kindergarten. Currently, the teachers say he is able to pay attention and he is well behaved in school. Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct. He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep: As stated before, he is having much difficulty on a consistent basis falling asleep. It is 12:00 to 1:00 a.m. before he falls to sleep. When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty. On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite: He will eat breakfast and supper, but not much lunch, if any at all. He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control: Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior. The only exception to this is he gets in occasional fights with his sisters. ABCD denies visual or auditory hallucinations or racing thoughts. He reports his thoughts are sometimes bad because he says sometimes he thinks of the \"S\" word.,Energy: Mother reports a lot of energy.,Pain: ABCD denies any pain in his body.,Suicidal or homicidal thoughts: He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06. He has received outpatient therapy from XYZ, LCSW. He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar. She reports she has significant moodiness episodes and believes in the past she has had a manic episode. She is currently not on medication. She does not know of anyone else in her family, with the exception of she said her father's behavior was \"weird.\" Biological father's side of the family, mother reports father was very impulsive. He had anger issues. He had drug and alcohol issues. He was in jail for three years for risky behavior. There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years. They divorced when ABCD was 2-1/2 years of age. Currently, father has been deported back to Mexico. He last saw ABCD in March 2006 for one day when they went down to AAAA. He does call on special holidays and his birthday. Contact is brief, but so far has been consistent. Mother is currently seeing R, a significant other, and has been seeing him for the last seven months. ABCD had a good relationship with R. ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as \"all wisdom.\",PREGNANCY:, Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero. She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:, Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:, Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:, Mother reports ABCD was a very cuddly infant and could sleep well. As a toddler, he was all over the place, climbing and always busy. Elementary school: In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen. ABCD has no history of fire setting or abuse to animals. He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:, Noncontributory.,MEDICAL STATUS AND HISTORY:, ABCD has no known drug allergies. He has no history of heart murmur, heart defect of other heart problems. No history of asthma, seizures or head injuries. He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:, When I asked ABCD whether he likes school, he stated, \"No.\" His grades are okay, per mother. He does have an IEP for the ADHD, but she does not believe he has a learning disability. Behavior problems: He currently is not having any behavior problems in the school. He reports he does not get along with his teachers because they tell him what to do. Strengths: He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:, He reports he has best friends. He named two, D and B, and he does have a friend that is a girl named Kim. When asked if church or God were important to him, he stated, \"God is.\" He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:, In the home, he has chores of taking out the trash.,LEGAL:, He has not been involved in the legal system.,SUPPORT SYSTEMS:, When asked if he feels safe in his home, he stated, \"Yes.\" When asked who he talks to if he is hurt or upset, he stated, \"Mom.\" (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:, He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:, This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions. ABCD kept himself occupied throughout and was very well behaved throughout the session. He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes. Distractibility and attention: He, at times, was very mildly distracted, but otherwise did not appear hyperactive. His judgment was adequate. When asked what he would do if there was a fire in his house, he said, \"Get out!\" Insight was poor to adequate. Fund of information was good. When asked who the president was, he said, \"George Washington.\" Intelligence is probably average to above average. Speech was normal. He had some difficulty with abstract thinking. He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle. On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly. When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly. Appearance was casual. Hygiene was good. Attitude was cooperative. Speech was normal. Psychomotor was between normal and slightly hyperactive. Orientation was x2. Attention/concentration was intact. Memory was intact at times and then had some memory recall problems with three words. Mood was euthymic. Affect was bright. He has no suicidal or homicidal/violence risks. Perceptions were normal. Thought process logical. Thought content normal. Disassociation none. Sleep: He is having some insomnia. Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:, He has a strong support system in his mother, grandmother, and mother's significant other, Richard. He has good health. He has shown gain from past treatment. He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior." }

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

{ "text_length": 9190 }

{ "text": "PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics of the procedure discussed. The procedure was discussed with father and mother as the patient is mentally challenged. He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year. He went to the emergency department yesterday with beef jerky.,All of this reviewed. The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP. He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency. He has not yet undergone significant workup. He has not yet had an endoscopy or barium study performed. He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture. The patient does not smoke, does not drink. He is living with his parents. Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress. Vital signs monitored in the endoscopy suite. Lungs clear. Cardiac exam showed regular rhythm. Abdomen obese but soft. Extremity exam showed large hands. He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother. Risks, benefits, and alternatives discussed. Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed. The potential need for a barium swallow, modified barium swallow, and similar discussed. All questions answered. At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture. He may have reflux symptoms, without complaining of heartburn. He may benefit from a trial of PPI. All of this reviewed. All questions answered.," }

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

{ "text_length": 2600 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy with decompression C6-C7.,2. Arthrodesis with anterior interbody fusion C6-C7.,3. Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4. PEEK implant 7 mm.,5. Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS: ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS: ,Round French 10 JP drain.,SPECIMENS,: None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:, This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped. The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07. This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow. She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear. She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level. Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level. Operation, expected outcome, risks, and benefits were discussed with her. Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma. There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function. Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics. However, the patient may develop deeper-seated infection, which may require return to the operating room. Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft. There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery. There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid. There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. There is also the risk of pseudoarthrosis and hardware failure. She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case. The EMGs were silent and there was no evidence of any stimulation. After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension. The head was supported on a foam doughnut. The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side. A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm. The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision. The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles. Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath. The prevertebral fascia was identified and cut sharply. A localizing x-ray verified the marker to be at the C6-C7 interspace. Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7. Self-retaining retractor was then laid out. The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr. The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7. There was note of a new osteophyte on the left C6-C7 foramen. This was carefully drilled down. After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders. They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam. After this was completed, Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant was then tapped into placed after its interior was packed with Vitoss. The plate was then applied and secured in place with four 12 x 4.7 mm screws. Irrigation of the area was done. A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis. The wound was reinforced with Dermabond. The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site. C-collar was placed and the patient was transferred to Recovery after extubation." }

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

{ "text_length": 6623 }

{ "text": "CHIEF COMPLAINT: , Altered mental status.,HISTORY OF PRESENT ILLNESS: , This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side, and he was crying and moaning. The sibling went and told the parents. The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body. He was initially alert, but his alertness diminished. They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed. The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services. Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room. For a small stop, I am obtaining an MRI and then admitting to the ICU. History was taken from the parents. He had a history of gastroesophageal reflux disease, otherwise, a healthy child.,MEDICATIONS: , None.,ALLERGIES:, No known drug allergies.,PAST SURGICAL HISTORY: , He had only tympanostomy tubes placed.,FAMILY MEDICAL HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:,GENERAL: He was brought by our transport team. While en route, he was not as alert as he was. He was still oriented. He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room. When I saw him, he was lethargic, but arousable. He could recognize where he was, and he could recognize also his parents well.,HEENT: Pupils are 4 mm reactive to direct and indirect light. No signs of trauma is seen on the head. Throat is clear.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm.,ABDOMEN: Soft.,NEUROLOGIC: He has left-sided weakness, but his cranial nerves II through XII are grossly intact.,EMERGENCY DEPARTMENT COURSE: , In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient. They decided to give him a dose of IV mannitol. I ordered his labs, type and cross. CBC is 15.6 white blood cell count, hemoglobin 12.8. PT/PTT were ordered due to the bleed, which was seen intracerebrally. They were 13.1 and 24.5 respectively. Blood gas, I-STAT pH 7.36, pCO2 is 51. This was a venous specimen. The ICU attendings decided to do a rapid sequence intubation. This was done in our emergency room by Dr. Y and Dr. Z. The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition.,DIFFERENTIAL DIAGNOSES: , Arteriovenous malformation, stroke, traumatic injury.,IMPRESSION: , Intracerebral hemorrhage of uncertain etiology to be determined while inpatient.,TIME SPENT:, I spent 30 minutes critical care time with the patient excluding any procedures.," }

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

{ "text_length": 3121 }

{ "text": "CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:, Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle.,REVIEW OF SYSTEMS:, He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising.,MEDICATIONS:, No daily medications.,ALLERGIES:, Cefzil.,IMMUNIZATIONS:, His immunizations are up to date.,PHYSICAL EXAMINATION:,General: He is alert and in no distress, afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Tanner III.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. No rashes.,Hearing: Grossly normal.,ASSESSMENT:, Well child.,PLAN:, Anticipatory guidance for age. He is to return to the office in one year." }

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

{ "text_length": 2222 }

{ "text": "INDICATIONS:, Chest pain.,PROCEDURE DONE:, Graded exercise treadmill stress test.,STRESS ECG RESULTS:, The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate. The blood pressure increased from 120/70 to 130/80. The baseline resting electrocardiogram reveals a regular sinus rhythm. The tracing is within normal limits. Symptoms of chest pain occurred with exercise. The pain persisted during the recovery process and was aggravated by deep inspiration. Marked chest wall tenderness noted. There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1. Stress test is negative for ischemia.,2. Chest wall tenderness occurred with exercise.,3. Blood pressure response to exercise is normal." }

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

{ "text_length": 941 }

{ "text": "CHIEF COMPLAINT:, This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotics for otitis media. Quality of ear problems: Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:, None currently.,PMH:, Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:, Parent admits child is in a large daycare.,FAMILY HISTORY:, Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM:, Temp: 99.6 Weight: 38 lbs.,Patient is a 3-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.,The child is accompanied by her mother who communicates well in English.,Head & Face: Inspection of head and face shows no abnormalities. Examination of salivary glands shows no abnormalities. Facial strength is normal.,Eyes: Pupil exam reveals PERRLA.,ENT: Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck: Neck exam reveals no abnormalities.,Lymphatic: No neck or supraclavicular lymphadenopathy noted.,Respiratory: Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric: Testing of cranial nerves reveals no deficits. Mood and affect normal and appropriate to situation.,TEST RESULTS:, Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.,PLAN:, Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003. Surgery will be performed at Children's Hospital. Pre-operative consent form read and signed by parent. Common risks and side effects of the procedure and anesthesia were mentioned. Parent questions elicited and answered satisfactorily regarding planned procedure. ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:, Augmentin Dosage: 400 mg-57 mg/5 ml powder for reconstitution Sig: One PO Q8h Dispense: 1 Refills: 0 Allow Generic: No" }

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

{ "text_length": 3265 }

{ "text": "CHIEF COMPLAINT: ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. A CT scan at ER did not show abscess. He has not had airway compromise, but he has had difficulty swallowing. He may have had a low-grade fever, but nothing marked at home. His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis. He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY: ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. He is a sophomore at High School.,FAMILY HISTORY: ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker. Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT: The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU: Denies dysuria.,Orthopedic: Denies joint pain, difficulty walking, etc.,Neuro: Denies headache, blurry vision, etc.,Eyes: Says vision is intact.,Lungs: Denies shortness of breath, cough, etc.,Skin: He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care. Mildly itchy. Mother has penicillin allergy.,Endocrine: The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General: This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4. Voice is normal. He is handling his secretions. There is no stridor.,Vital Signs: See vital signs in nurses notes.,Ears: TM and EACs are normal. External, normal.,Nose: Opening clear. External nose is normal.,Mouth: Has bilateral marked exudates, tonsillitis, right greater than left. Uvula is midline. Tonsils are touching. There is some redness of the right palatal area, but is not consistent with peritonsillar abscess. Tongue is normal. Dentition intact. No mucosal lesions other than as noted.,Neck: No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest: Clear to auscultation.,Heart: No murmurs, rubs, or gallops.,Abdomen: Obese. Complete exam deferred.,Skin: Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro: Cranial nerves II through XII are intact. Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. No significant prior history of tonsillitis. Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral. I do not insist that this patient will need surgical intervention since there is no evidence of abscess. This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient. The patient's parents in the room had expressed good understanding, have a chance to ask questions. At this time, I will see the patient back on an as needed basis." }

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

{ "text_length": 3951 }

{ "text": "HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED: ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver. No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION: ,1. Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. Hypercholesterolemia.,4. History of anxiety.,5. History of coronary artery disease.,6. Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X. Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation. I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern." }

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

{ "text_length": 1345 }

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

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

{ "text_length": 1642 }

{ "text": "TITLE OF OPERATION:, Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA: ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:, Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in a normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized. The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved. The bony prominences were removed and passed off the operating table to be sent to pathology for identification. The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp. The area was copiously flushed with saline. Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively. The incision was reinforced with Steri-Strips. Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited. The patient's left ankle tourniquet at this time was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe. The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medications and instructions on how to control her postoperative course. She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment." }

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

{ "text_length": 3483 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY: ,Pending.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems." }

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

{ "text_length": 2602 }

{ "text": "CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid. It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1. Red, irritated eye.,2. Some burning and/or scratchy feeling.,3. There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye. It may or may not need medication for treatment. If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1. Wash hands thoroughly before you use the medicine in your eyes. After using the medicine in your eyes. Every time you touch your eyes or face.,2. Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3. Do not share make-up. If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4. Do not touch the infected eye because the infection will spread to the good eye. IMPORTANT!!!,5. Pink Eye Spreads Very Easily!" }

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

{ "text_length": 1021 }

{ "text": "TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist." }

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

{ "text_length": 4778 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS: ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS: ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition." }

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

{ "text_length": 2725 }

{ "text": "INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduced into the rectum. Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions. The rest of the colon through to the cecum was well visualized. The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified. There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation. Adverse reactions none.,IMPRESSION:, Normal colonic mucosa through to the cecum. There was no evidence of tumor or polyp." }

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

{ "text_length": 806 }

{ "text": "PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition." }

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

{ "text_length": 4688 }

{ "text": "EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:, A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy. Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes. There are subtle areas of increased attenuation seen within the frontal lobes bilaterally. Given the patient's clinical presentation, these likely represent small hemorrhagic contusions. Other differential considerations include cortical calcifications, which are less likely. The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation. The orbits and extra-ocular muscles are within normal limits. There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia. There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation. The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis. The central canal is grossly patent. The pedicles and posterior elements appear intact with multifocal facet degenerative changes. There is no prevertebral or paravertebral soft tissue masses identified. The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions. There is no associated shift or mass effect at this time. Less likely, this finding could be secondary to cortical calcifications. The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation." }

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

{ "text_length": 3088 }

{ "text": "HISTORY: ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support. He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility. He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site. He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed. Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck. No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY: ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY: ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:, Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL: The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection. The previous incision was vertical in nature and there is no hypertrophic scar formation. No adenopathy noted. No stridor noted.,NEUROLOGIC: Cranial nerve VII intact bilaterally. No signs of tremor.,LUNGS: Diminished breath sounds in all four quadrants. No wheezes noted.,HEART: Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION: ,1. End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2. Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3. History of coronary artery disease.,4. History of myocardial infarction.,5. History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube. His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility. I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed. Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time. The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today. Dressing was applied and we will see him back next week to make sure everything is healing properly." }

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

{ "text_length": 5233 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Bilateral breast carcinoma.,2. Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1. Bilateral breast carcinoma.,2. Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE: ,With the patient under satisfactory general orotracheal anesthesia and in the supine position, the right upper anterior chest, neck, and arm were prepared with Betadine in the usual fashion. The skin, subcutaneous tissue, and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0.5% Marcaine with epinephrine. An incision transverse, parallel, and inferior to the middle third of the right clavicle was performed. A subcutaneous pocket on the surface of the pectoralis major muscle was created. The muscular fascia was also infiltrated with 0.5% Marcaine with epinephrine. With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated. A guidewire was passed without difficulty and the needle was removed. Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium. A dilator and sheath was passed over the guidewire. The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn. Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava. The catheter had been preflushed with dilute heparin solution (100 units/mL). The port, which had been preflushed with saline, was attached to the catheter at approximately 13 cm level. The locking cap had been placed on the catheter. The port was connected to the catheter and the locking cap was secured. The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket. Fluoroscopy again confirmed satisfactory position. A hard copy of the fluoroscopy was obtained. The catheter and port were secured to the pectoralis fascia in four locations with 2-0 Prolene suture. Site was irrigated with saline. Hemostasis was verified. The subcutaneous tissue was approximated with interrupted 2-0 Vicryl suture. The subcutaneous and dermis were closed with a running subcuticular 3-0 Vicryl suture. A 0.25-inch Steri-Strips were applied. The provided needle and butterfly attachment was flushed with saline, passed through the skin into the port, and then flushed again with dilute heparin solution thus confirmed satisfactory. The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4's and paper tape. Estimated blood loss was less than 15 mL. The patient tolerated the procedure well and left the operating room in good condition." }

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

{ "text_length": 2835 }

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

{ "text_length": 6766 }

{ "text": "REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:, She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:, None.,PAST MEDICAL HISTORY: , No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.,SOCIAL HISTORY: ,She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.,FAMILY HISTORY: ,Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL: She is in no acute distress.,VITAL SIGNS: The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN: Warm and dry. She has no jaundice.,LYMPHATICS: No cervical or supraclavicular lymph nodes are palpable.,LUNGS: There is no respiratory distress.,CARDIAC: Regular rate.,ABDOMEN: Soft and mildly tender. Dressings are clean and dry.,EXTREMITIES: No peripheral edema is noted. Sequential compression devices (SCDs) are in place.,LABORATORY DATA:, White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.,She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow." }

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

{ "text_length": 5885 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,5. Possible adenomyosis.,6. Left hydrosalpinx.,7. Suspicion for endometriosis.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:, None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion. This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living. Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996. The cyst was not diagnosed as an endometrioma. The patient does desire future fertility; however, would like a definitive diagnosis. Conservative medical therapy was offered i.e. Lupron or repeat oral contraceptives, but declined.,FINDINGS:, Bimanual exam reveals a small retroverted uterus which is easily mobile. There were no adnexal masses. The cervix was normal on palpation. A fibrotic band was noted at the internal os during dilation. On laparoscopic exam, the uterus was found to be small with mild spongy texture. On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis. The left ovary was grossly normal. The left fallopian tube had a mild hydrosalpinx present. The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis. The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac. The liver appeared grossly normal. There were no obvious pelvic adhesions. The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE: ,The patient was seen in the preop suite. History was reviewed and all questions were answered. The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube. She was placed in a dorsal lithotomy position in Allen stirrups. She was prepped and draped in the normal sterile fashion. Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine. A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted. A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum. There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible. A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen. An infraumbilical incision was made using skin scalpel. The Veress needle was placed and CO2 was insufflated. It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed. A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure. The #12 port was placed and the laparoscope was inserted. Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position. The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette. A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation. This procedure was performed under direct laparoscopic visualization. Laparoscopic evaluation of the pelvis was performed and the above findings noted. A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization. A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization. The manipulator was then removed and the Harmonic scalpel was placed through the #5 port. The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament. The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis. There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment. The Harmonic scalpel was removed from the abdomen as was the #5 port. The incision was internally found to be hemostatic. The laparoscope was then removed from the abdomen. The abdomen was desufflated. The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen. The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic. The weighted speculum was then removed. The patient taken out of dorsal lithotomy position. She was recovered from general anesthesia and taken to the postoperative suite for complete recovery. The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology. Her family was notified of the findings. She will be instructed not to have intercourse or use tampons or douche for the next two weeks. The patient will be sent home with a prescription for Darvocet for pain." }

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

{ "text_length": 5965 }

{ "text": "REASON FOR THE VISIT:, Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again. I gave her the Coumadin as an outpatient and then the INR was found to be 12. So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1. Congestive heart failure.,2. Renal insufficiency.,3. Coronary artery disease.,4. Atrial fibrillation.,5. COPD.,6. Recent pneumonia.,7. Bladder cancer.,8. History of ruptured colon.,9. Myocardial infarction.,10. Hernia repair.,11. Colon resection.,12. Carpal tunnel repair.,13. Knee surgery.,MEDICATIONS:,1. Coumadin.,2. Simvastatin.,3. Nitrofurantoin.,4. Celebrex.,5. Digoxin.,6. Levothyroxine.,7. Vicodin.,8. Triamterene and hydrochlorothiazide.,9. Carvedilol.,SOCIAL HISTORY: ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL: Lady in no distress.,VITAL SIGNS: Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT: Head is normal.,NECK: Supple.,LUNGS: Clear to auscultation and percussion.,HEART: No S3, no S4, and no murmurs.,ABDOMEN: Soft.,EXTREMITIES: Lower extremities, no edema.,ASSESSMENT:,1. Atrial fibrillation.,2. Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12. I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week. I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her. She is prone to a fall and this would be a big problem. We will use one aspirin a day instead of the anticoagulation. She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand. We will see her as an outpatient." }

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

{ "text_length": 2354 }