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Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

REASON FOR CONSULT:, Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating. He reported that he called 911 secondary to noticing bilious vomiting and dry heave. The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years. He has been away from work secondary to alcohol cravings and drinking. He has also experienced marital and family conflict as a result of his drinking habit. On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily. He reports a history of withdrawal symptoms, but denied history of withdrawal seizures. His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings. The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit. He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits. He denies depressive symptoms. He denies any psychotic symptoms or perceptual disturbances. There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations. The patient denies any history of suicidal attempts. There is no history of inpatient rehabilitation programs. He has attended AA for periodic moments throughout the past few years. He has been treated with Antabuse before.,PAST MEDICAL HISTORY:, The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:, No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance. No other psychiatric illnesses in the family.,SOCIAL HISTORY:, The patient has been divorced twice. He has two daughters one from each marriage, ages 15 and 22. He works as a geologist at Petrogas. He has limited contact with his children. He reports that his children's mothers have turned them against him. He and his wife have experienced marital discord secondary to his alcohol use. His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss. There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:, This is a well-groomed male. He appears his stated age. He is lying comfortably in bed. There are no signs of emotional distress. He is pleasant and engaging. There are no psychomotor abnormalities. No signs of tremulousness. His speech is with normal rate, volume, and inflection. Mood is reportedly okay. Affect euthymic. Thought content, no suicidal or homicidal ideations. No delusions. Thought perception, there are no auditory or visual hallucinations. Thought process, Logical and goal directed. Insight and judgment are fair. The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:, CBC: WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000. BMP: Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0. LFTs: ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2. PFTs within normal limits.,IMAGING:, CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver. No splenomegaly.,ASSESSMENT:, This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver. The patient currently has no signs of withdrawal. The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use. The patient had severe insomnia that is likely secondary to alcohol use. Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:, Axis I: Alcohol dependence.,Axis II: Deferred.,Axis III: Fatty liver, esophagitis, and hypertension.,Axis IV: Marital discord, estranged from children.,Axis V: Global assessment of functioning equals 55.,RECOMMENDATIONS:,1. Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient. Discontinue outpatient Restoril. The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2. Continue Alcoholics Anonymous meetings to maintain abstinence.,3. Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4. Supplement with multivitamin, thiamine, and folate upon discharge and before. Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached. Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5. Alcohol education and counseling provided during consultation.,6. Trazodone 50 mg p.o. q.h.s. for insomnia.,7. Follow up with PCP in 1 to 2 weeks.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

REASON FOR CONSULTATION:, Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia. The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. Foley catheter was repositioned 18 Coude was used. About over a liter of fluids of urine was obtained with light pink urine, which was irrigated. The bladder and the suprapubic area returned to normal after the Foley placement. The patient had some evidence of clots upon irrigation. The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY: ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:, No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting. Does have suprapubic tenderness and difficulty voiding. The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Vitals are stable.,GENERAL: The patient is a thin gentleman,GENITOURINARY: Suprapubic area was distended and bladder was palpated very easily. Prostate was 1+. Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000. Creatinine is normal.,ASSESSMENT AND PLAN:,1. Pneumonia.,2. Dehydration.,3. Retention.,4. BPH.,5. Diabetes.,6. Hyperlipidemia.,7. Parkinson's.,8. Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained. Plan is for urine culture, antibiotics. Plan is for renal ultrasound to rule out any pathology. The patient will need cystoscopy and evaluation of the prostate. Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time. Continued Foley catheter at this point. We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.

Urology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.,RESPIRATORY: ,Clear to auscultation and percussion. No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.,SKIN: , No rashes or lesions. No petechia. No purpura. Good turgor. No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.,MUSCLE: ,No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.,LYMPHATIC:, Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:, Historical information was obtained from a review of available medical records and clinical interview with Ms. A. 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:, Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. Neurological evaluation with Dr. X confirmed left hemiparesis. Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness. These symptoms were thought to be due to a right middle cerebral artery stroke. She was transferred to the ICU for monitoring. Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA. On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA. At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane. She was discharged home with recommendations for outpatient physical therapy. She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup. Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change. MRI could not be completed due to the patient's weight. She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted. She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at. Note also that she had some difficulty explaining exactly what her job involved. She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY: ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it "every other night." When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:, Ms. A denied drinking alcohol or using illicit drugs. She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree. She reported that she primarily obtained B's and C's in school. She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing. As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. She is now living on her own. She has never driven. She reported that she continues to perform ADLs independently such as cooking and cleaning. She lost her husband in 2005 and has three adult daughters. She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. She also reported number of other family members who had recently passed away. She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes.",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

Psychiatry / Psychology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Endocrinology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Neurology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1. Lumbar discogram L2-3.,2. Lumbar discogram L3-4.,3. Lumbar discogram L4-5.,4. Lumbar discogram L5-S1.,ANESTHESIA: ,IV sedation.,PROCEDURE IN DETAIL: ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.

Radiology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history of premature babies in the past. This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%. He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL: He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS: Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN: He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy. He has evidence for significant pulmonary hypertension. A large ductus arteriosus was seen with bidirectional shunt. A foramen ovale shunt was also noted with bidirectional shunt. The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension. The best therapy for this is to continue oxygen. If clinically worsens, he may require nitric oxide. Certainly, Indocin should not be used at this time. He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.

Pediatrics - Neonatal

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. Rest of visualized exam nonacute/stable.,3. Left central line appropriately situated and stable.,4. Preliminary report was issued at time of dictation. Dr. X was called for results.

Radiology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:, Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE: ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness. He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder. He was worked up by the emergency department. His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage. Oral maxillary facial surgery was consulted to manage the mandible fracture. After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures. Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital. He was laid in supine position on the operating room table. ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion. The surgeon approached the operating room table in a sterile fashion. Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion. Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior. This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth. The patient was manipulated up into maximum intercuspation. He has a malocclusion with severe bruxism and so wear facets were lined up. This was secured with 26-gauge surgical steel wire. Attention was then directed to the symphysis extraorally. Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made. Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible. The periosteum was incised and reflected with the periosteal elevator. The fracture was noted and it was displaced. Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned. This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws. The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture. Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule. After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified. It was noted that the fracture went through tooth #17 and this needed to be extracted. Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots. The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed. The fracture was noted to be well reduced. The wound was then irrigated with copious amount of sterile water. The patient was released for excellent intercuspation. He was then manipulated up into the occlusion easily. Wound was then closed with running 3-0 chromic gut suture. Attention was then directed extraorally. This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin. Attention was then again directed into the mouth. The throat pack was removed and orogastric tube was placed and stomach content was evacuated. The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions. At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

CHIEF COMPLAINT:, Dental pain.,HISTORY OF PRESENT ILLNESS:, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion.,PROCEDURE:, Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN: ,The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.

Ophthalmology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

DATE OF EXAMINATION: , Start: 12/29/2008 at 1859 hours. End: 12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:, 12 hours, 29 minutes.,PATIENT HISTORY:, This is a 46-year-old female with a history of events concerning for seizures. The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1. Awake: Normal.,2. Sleep: Activation of a single left temporal spike seen maximally at T3.,3. Clinical events: None.,DESCRIPTION: ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed. During the waking state, there is a 9-Hz dominant posterior rhythm. The background of the record consists primarily of alpha frequency activity. At times, during the waking portion of the record, there appears to be excessive faster frequency activity. No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained. A single left temporal, T3, spike is seen in sleep. Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION: ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep. The patient had no clinical events during the recording period. Clinical correlation is required.

Neurology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

HISTORY OF PRESENT ILLNESS: ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure. He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS: Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT: Unremarkable.,LUNGS: Clear.,CARDIOVASCULAR: An irregular rhythm.,ABDOMEN: Soft.,EXTREMITIES: His upper extremities are well perfused. He has palpable radial and femoral pulses. He does not have any palpable pedal pulses in either right or left lower extremity. He does have reasonable capillary refill in both feet. He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm. Apparently, this was lot worst few hours ago. He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent. He currently has a viable extremity and viable foot, but certainly has significant making compromised flow. It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention. He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime. Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization. We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate. Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity. We will follow him along closely.

Emergency Room Reports

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.,HEART: Regular rhythm and rate.,ABDOMEN: Soft, less tender.,LABORATORY DATA:, Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:, She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.

SOAP / Chart / Progress Notes

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagittal and coronal images were obtained.,DISCUSSION:, There are numerous subcentimeter nodules seen within the lung bases. The largest measures up to 6 mm. No hiatal hernia is identified. Consider chest CT for further evaluation of the pulmonary nodules. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits. No dilated loops of bowel. There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat. In addition, there is soft tissue stranding seen of the lower pelvis. In addition, the uterus is not identified. Correlate with history of recent surgery. There is no free fluid or lymphadenopathy seen within the abdomen or pelvis. The bladder is within normal limits for technique.,No acute bony abnormalities appreciated. No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1. Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2. Numerous subcentimeter nodules seen within the lung bases. Consider chest CT for further characterization.

Nephrology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

INDICATION: ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60. EKG normal sinus rhythm. The patient exercised on Bruce for 8 minutes on stage III. Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. Total METs was 10.1. EKG revealed nonspecific ST depression in inferior and lateral leads. The test was terminated because of fatigue. The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1. Positive exercise ischemia with ST depression 0.5 mm.,2. Chest pain resolved after termination of exercise.,3. Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 68%. End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 68% by gated SPECT.

Cardiovascular / Pulmonary

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

None

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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.

General Medicine

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.

Obstetrics / Gynecology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history of premature babies in the past. This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%. He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL: He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS: Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN: He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy. He has evidence for significant pulmonary hypertension. A large ductus arteriosus was seen with bidirectional shunt. A foramen ovale shunt was also noted with bidirectional shunt. The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension. The best therapy for this is to continue oxygen. If clinically worsens, he may require nitric oxide. Certainly, Indocin should not be used at this time. He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Orthopedic

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.

Cardiovascular / Pulmonary

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout. She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993. She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash. The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker. She only drinks socially one to two drinks a month. She is employed as a manager at the New York department of taxation. She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure. She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes. She also complains about snoring and occasional slight asthma. She does complain about peripheral ankle swelling and heartburn. She also gives a history of hemorrhoids and bladder infections in the past. She has weight bearing joint pain as well as low back degenerating discs. She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION: ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20. Well nourished, well developed in no distress. Eye exam, pupils equal round and reactive to light. Extraocular motions intact. Neuro exam deep tendon reflexes 1+ in the lower extremities. No focal neuro deficits noted. Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit. Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished. Cardiac exam regular rate and rhythm without murmur or bruit. Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen. No palpable tenderness. No right upper quadrant tenderness. No organomegaly appreciated. No obvious hernias noted. Lower extremity exam +1 edema noted. Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities. The patient is interested in gastric bypass surgery. The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels. Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively. I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.

Bariatrics

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition.

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

None

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

SUBJECTIVE:, The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam. Her last Pap smear was 05/02/2002. Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest. Has awakened her at night on occasion and only last about 15 to 20 minutes. Denies nausea, vomiting, diaphoresis or shortness of breath with it. This has not happened in almost two months. She had a normal EKG one year ago. Otherwise, has been doing quite well. Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:, Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:, Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:, None.,SOCIAL HISTORY:, She is married. Denies tobacco, alcohol and drug use. She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:, HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs: Weight 146. Blood pressure 100/64. Pulse 80. Respirations 16. Temperature 97.7.,General: She is a well-developed, well-nourished white female in no acute distress.,HEENT: Grossly within normal limits.,Neck: Supple. No lymphadenopathy. No thyromegaly.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm.,Abdomen: Positive bowel sounds, soft and nontender. No hepatosplenomegaly.,Breasts: No nipple discharge. No lumps or masses palpated. No dimpling of the skin. No axillary lymph nodes palpated. Self-breast exam discussed and encouraged.,Pelvic: Normal female genitalia. Atrophic vaginal mucosa. No cervical lesions. No cervical motion tenderness. No adnexal tenderness or masses palpated.,Rectal: Normal sphincter tone. No stool present in the vault. No rectal masses palpated.,Extremities: No cyanosis, clubbing or edema. She does have obvious rheumatoid arthritis of her hands.,Neurologic: Grossly intact.,ASSESSMENT/PLAN:,1. Chest pain. The patient will evaluate when it happens next; what she has been eating, what activities she has been performing. She had normal ECG one year ago. In fact this does not sound cardiac in nature. We will not do further cardiac workup at this time. Did discuss with her she may be having some GI reflux type symptoms.,2. Hypothyroidism. We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3. Rheumatoid arthritis. Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4. Osteoporosis. It is time for her to have a repeat DEXA at this time and that will be scheduled.,5. Health care maintenance, Pap smear was obtained today. The patient will be scheduled for mammogram.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSES:,1. Recurrent bladder tumor.,2. History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,

Nephrology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

General Medicine

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

Endocrinology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper. Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:, The patient and her daughter completed both days of diabetes education in a group setting. Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician. Fasting blood sugars are 127, 80, and 80. Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63. Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109. Assessment of her knowledge is completed at the end of the counseling session. She demonstrated increased knowledge in all areas and had no further questions. She also completed an evaluation of the class.,The patient's feet were examined during the education session. She had flat feet bilaterally. Skin color was pink, temperature warm. Pedal pulses 2+. Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care. First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels. Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control. Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control. Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:, Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness. She is to followup with Dr. XYZ for possible reduction in her insulin doses.

Diets and Nutritions

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:, None. The patient was taken to Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder. X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid. She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head. All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention. The patient still wanted to proceed forward with surgical intervention. The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The patient was moved to a beach chair position. All extremities were well padded. Her head was well padded to the table. Her right upper extremity was draped in sterile fashion. A saber incision was made from the coracoid down to the axilla. Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case. Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made. Subscapularis tendon was released. The humeral head was brought in to; there were large osteophytes that were removed with an osteotome. The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region. A sizer was placed. It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin. This was placed, after which a reamer was placed along the humeral head and reamed to a size 5. All extra osteophytes were excised. The supraspinatus and infraspinatus tendons were intact. Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation. The arm had excellent range of motion. There are no signs of gross dislocation. Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head. Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position. After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction. There was no gross sign of dislocation. Wound site once again it was copiously irrigated with saline antibiotics. The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon. After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl. The skin was closed with staples. A sterile dressing was placed. The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.

Orthopedic

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:, The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. After this, the patient was then prepped and draped with Hibiclens. A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. After this, the patient's anterior trachea was then identified and cleaned with pusher. After this, the cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker. After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage. After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap. After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.

Surgery

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS: , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:, Urology.,PROCEDURES DURING THIS HOSPITALIZATION:, On MM/DD/YYYY, ,1. Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2. Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY. He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement. Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The procedure was without complications. The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation. He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. We advanced him as tolerated to a regular health select diet by postoperative day #4. His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used. He was then switched over to p.o. pain medicines and has required very little for adequate pain control. By postoperative date #2, the patient had been out of bed and ambulating in the hallways. The patient's only problem was with some mild diarrhea on postoperative days #3 and 4. This was thought to be a result of his right hemicolectomy. A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea. His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints. He had been afebrile throughout his hospitalization and his vital signs were stable. Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. His midline incision is clean, dry, and intact and staples are in place. He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE: ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1. Multivitamins daily.,2. Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3. Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4. Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5. Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:, The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time.

Discharge Summary

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

HISTORY: ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath. The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies. She never had treated hypertension. She said the blood pressure came down. She is obviously very hypertensive this evening. She has some mid scapular chest discomfort. She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:, Does not smoke, lipids unknown. Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:, Negative for coronary disease. Dad died of lung cancer.,DRUG SENSITIVITIES:, Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:, Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision. Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above. No reflux, abdominal distress. No other types of indigestion, GI bleed. GU: Negative. She is unaware of any kidney disease. Did not have arthritis or gout. No back pain or surgical joint treatment. Did not have claudication, carotid disease, TIA. All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS: Presenting blood pressure was 170/120 and her pulse at that time was 137. Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic. Saturation of 86%. Currently, blood pressure 120/70, heart rate is down to 100.,EYES: No icterus or arcus.,DENTAL: Good repair.,NECK: Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS: Fine and coarse rales, lower two thirds of chest.,HEART: Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split. There is loud third heart sound. No murmur.,ABDOMEN: Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL: No acute joints.,EXTREMITIES: Good pulses. No edema.,NEUROLOGICALLY: No focal weakness.,MENTAL STATUS: Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:, All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1. Acute pulmonary edema.,2. Physical findings of dilated left ventricle.,3. Left bundle-branch block.,4. Breast cancer in 1992.,PLAN: ,Admit. Aggressive heart failure management. Get echo. Start ACE and Coreg. Diuresis of course underway.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PAST MEDICAL HISTORY: Include:,1. Type II diabetes mellitus.,2. Hypertension.,3. Hyperlipidemia.,4. Gastroesophageal reflux disease.,5. Renal insufficiency.,6. Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7. Enterocutaneous fistula.,8. Respiratory failure.,9. History of atrial fibrillation.,10. Obstructive sleep apnea.,11. History of uterine cancer, status post total hysterectomy.,12. History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY: The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY: Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS: Currently include,,1. Albuterol inhaler q.4 h.,2. Paradox swish and spit mouthwash twice a day.,3. Digoxin 0.125 mg daily.,4. Theophylline 50 mg q.6 h.,5. Prozac 20 mg daily.,6. Lasix 40 mg daily.,7. Humulin regular high dose sliding scale insulin subcu. q.6 h.,8. Atrovent q.4 h.,9. Lantus 12 units subcu. q.12 h.,10. Lisinopril 10 mg daily.,11. Magnesium oxide 400 mg three times a day.,12. Metoprolol 25 mg twice daily.,13. Nitroglycerin topical q.6 h.,14. Zegerid 40 mg daily.,15. Simvastatin 10 mg daily.,ALLERGIES: Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS: The patient currently denies any pain, denies any headache or blurred vision. Denies chest pain or shortness of breath. She denies any nausea or vomiting. Otherwise, systems are negative.,PHYSICAL EXAM:,General: The patient is awake, alert, and oriented. She is in no apparent respiratory distress.,Vital Signs: Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24. The patient has a tracheostomy in place. She will also have an esophageal gastric tube in place.,Cardiac: Regular rate and rhythm without audible murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases. No adventitious sounds are noted.,Abdomen: Obese. There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery. The area is covered with bandage with serosanguineous fluid. Abdomen is nontender to palpation. Bowel sounds are heard in all 4 quadrants.,Extremities: Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA: Pending. Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT: This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN: For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours. The patient had been previously controlled on this. We will continue to check her sugars every 6 hours and adjust insulin as necessary.

Consult - History and Phy.

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition.

Pain Management

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2. Old coronary infarct, anterior aspect of the right external capsule.,3. Acute bronchitis with reactive airway disease.,4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5. Atherosclerotic cardiovascular disease.,6. Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good.

Cardiovascular / Pulmonary

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

ASH SPLIT VENOUS PORT,PROCEDURE DETAILS: ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion. Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter. The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle. Under fluoroscopic control, a J-wire was advanced into the right atrium. The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel. A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision. The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control. The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system. The sheath was peeled away, leaving the catheter into position. Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position. The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture "wings.",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied. Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.

Cardiovascular / Pulmonary

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

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

Radiology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam.

ENT - Otolaryngology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed. The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan. The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast. Multiphase retrospective reconstructions were performed. Small field of view cardiac and coronary images were analyzed on a 3D work station. Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1. The technical quality of the scan is adequate.,2. The coronary ostia are in their normal position. The coronary anatomy is right dominant.,3. LEFT MAIN: The left main coronary artery is patent without angiographic stenosis.,4. LEFT ANTERIOR DESCENDING ARTERY: The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity. Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5. The ramus intermedius is a small vessel with minor irregularities.,6. LEFT CIRCUMFLEX: The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7. RIGHT CORONARY ARTERY: The right coronary artery is a large and dominant vessel. It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity. Left ventricular ejection fraction is calculated to be 69%. There are no wall motion abnormalities.,8. Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1. Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.

Radiology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY: ,1. Diabetes mellitus diagnosed 12 years ago.,2. Hypertension.,3. Coronary artery disease with a myocardial infarct in September of 2006.,4. End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY: ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:, Hypertension.,PHYSICAL EXAMINATION: ,GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR: Regular rate and rhythm.,PULMONARY: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.

Nephrology

Given a medical transcription, predict a single label representing the most appropriate medical specialty from the list: 'Surgery', 'Allergy / Immunology', 'Sleep Medicine', 'Pediatrics - Neonatal', 'SOAP / Chart / Progress Notes', 'Bariatrics', 'Pain Management', 'Lab Medicine - Pathology', 'Dermatology', 'Orthopedic', 'Dentistry', 'Psychiatry / Psychology', 'General Medicine', 'Office Notes', 'Letters', 'Neurosurgery', 'Radiology', 'Cosmetic / Plastic Surgery', 'Nephrology', 'Diets and Nutritions', 'Chiropractic', 'Gastroenterology', 'Cardiovascular / Pulmonary', 'Speech - Language', 'Hospice - Palliative Care', 'Autopsy', 'Endocrinology', 'Emergency Room Reports', 'Discharge Summary', 'ENT - Otolaryngology', 'Urology', 'Physical Medicine - Rehab', 'Neurology', 'Podiatry', 'Ophthalmology', 'Rheumatology', 'IME-QME-Work Comp etc.', 'Hematology - Oncology', 'Consult - History and Phy.', 'Obstetrics / Gynecology'

PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS: ,3 units of packed cells.,DRAINS:, None.,COMPLICATIONS: , None.,PROCEDURE: ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma. Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery. The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps. The bone flap, which had not been fixed in place was removed. An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation. Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery. It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex. The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior. This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation. Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission. Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation. Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel. Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard. The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region. The wound was then closed. It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap. The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

Neurosurgery