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

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

{ "text_length": 806 }

{ "text": "CHIEF COMPLAINT:, Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:, This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals: Wt; 172 lbs, up 2 lbs, B/P; 150/60, T; 96.4, P; 72 and regular. ,General: A 78-year-old male who does not appear to be in any acute distress. Glasses. Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen: Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities: Well-healed surgical scar on the right knee. No edema. Hand grasps are strong and equal.,Back: Surgical scar on the lower back.,Neuro: Intact. A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1. Hypertension.,2. Hypercholesterolemia.,3. Osteoarthritis.,4. Fatigue.,PLAN:, We will check a BMP, lipid, liver profile, CPK, and CBC. Refill his medications x 3 months. I gave him a copy of Partners in Prevention. Increase his Altace to 5 mg day for better blood pressure control. Diet, exercise, and weight loss, and we will see him back in three months and p.r.n." }

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

{ "text_length": 1785 }

{ "text": "CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY: ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES: ,None.,PHYSICAL EXAMINATION:,GENERAL: This is a pleasant white male in no acute distress.,VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits.,HEENT: Negative for acute evidence of trauma, injury or infection.,LUNGS: Clear.,HEART: Regular rate and rhythm with S1 and S2.,ABDOMEN: Soft.,EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified.,BACK EXAM: Nontender.,NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident." }

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

{ "text_length": 2970 }

{ "text": "CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:, A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly., ,PAST MEDICAL HISTORY:, Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.,General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull." }

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

{ "text_length": 1271 }

{ "text": "HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a \"quick lift\" type procedure certainly would address these issues. I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center." }

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

{ "text_length": 1006 }

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

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

{ "text_length": 3029 }

{ "text": "EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above." }

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

{ "text_length": 1224 }

{ "text": "PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:, Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES: ,1. Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2. Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow. After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure. Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve. At that same time, the patient's mildly angulated radial shaft fracture will be reduced. This was explained to the father. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms. All questions were answered. The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The left upper extremity was then prepped and draped in the standard surgical fashion. Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful. It was decided at this time that she would need open reduction. The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg. The Esmarch was then removed. An incision was then made. Care was taken to avoid any injury to the ulnar nerve. The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint. This was easily removed. The ulnar nerve was also identified, and appeared to be intact. The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place. After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement. The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl. The wound was clean and dry, dressed with Steri-Strips and Xeroform. The area was infiltrated with 0.5% Marcaine. The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation. The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding. Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed. The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age. The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days. The father was made aware of the intraoperative findings. All questions answered." }

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

{ "text_length": 4220 }

{ "text": "CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of \"old age.\" Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104. HR 92. RR 12. Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit." }

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

{ "text_length": 4004 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet applied to the upper arm. The extremity was prepped in a usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine. A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint. The tourniquet was released. Circulation returned to the fingers. The patient then was allowed to awaken and left the operating room in good condition." }

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

{ "text_length": 1588 }

{ "text": "CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:" }

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

{ "text_length": 1690 }

{ "text": "REASON FOR VISIT: ,The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory. When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder. He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years. At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself. They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin. As time progressed, he developed more and more difficulty. He started to shuffle. He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006. At this point, he frequently if not always has trouble getting in or out of the seat. He frequently tends to lean backwards or sideways when sitting. He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking. He has not fallen in the last month. He did fall earlier, but there seemed to be fewer opportunities for him to fall. His family has recently purchased a lightweight wheelchair to use if he is traveling long distances. He has no stairs in his home, however, his family indicates that he would not be able to take stairs. His handwriting has become smaller and shakier.,In regard to the bladder, he states, \"I wet the bed.\" In talking with his family, it seems as if he has no warning that he needs to empty his bladder. He was diagnosed with a small bladder tumor in 2005. This was treated by Dr. Y. Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence. The patient has worn a pad or undergarment for at least one to one and a half years. His wife states that they go through two or three of them per day. He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates. Now he seems less spontaneous and his family states he seems to have trouble expressing himself. His wife took over his medications about two years ago. She stopped his driving about three years ago. She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more. Apparently, he did not object. At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home. He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth. He is a retired office machine repairman. He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease. He has been treated for the bladder. He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998. The bladder tumor was discovered in 2005 and was treated noninvasively. He has lost weight from about 200 pounds to 180 pounds over the last two or three years. He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped. He used to drink a significant amount of alcohol. This was problematic enough that his wife was concerned. She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY: ,He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches.,FAMILY HISTORY: ,His grandfather had arthritis. His father had Parkinson's disease. His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker. He is well developed, well nourished, and kempt.,Vital Signs: His weight is 180 pounds.,Head: The head is normocephalic and atraumatic. The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine: The spine is straight and not tender. I can easily palpate the spinous processes. There is no scoliosis.,Skin: No neurocutaneous stigmata.,Cardiovascular Examination: No carotid or vertebral bruits.,Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 17/30. He did not know the year, season, or day of the week nor did he know the building or specialty or the floor. There was a tendency for perseveration during the evaluation. He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam: No evidence of papilledema. The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam: Normal bulk and strength, but the tone is marked by significant paratonia. There is no atrophy, fasciculations, or drift. There is tremulousness of the outstretched hands.,Sensory Exam: Is difficult to interpret. Either he does not understand the test or he is mostly guessing.,Cerebellar Exam: Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests. There is no dysarthria.,Reflexes: Trace in the arms, 2+ at the knees, and 0 at the ankles. It is not certain whether there is a Babinski sign or simply withdrawal.,Gait: Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology. It shows the ventricles are enlarged with a frontal horn span of 5.0 cm. The 3rd ventricle contour is flat. The span is enlarged at 12 mm. The sylvian aqueduct is patent. There is a pulsation artifact. The corpus callosum is effaced. There are extensive T2 signal abnormalities that are confluent in the corona radiata. There are also scattered T2 abnormalities in the basal ganglia. There is a suggestion of hippocampal atrophy. There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus. His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment. His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1. Possible idiopathic normal pressure hydrocephalus (331.5).,2. Probable cerebral small-vessel disease (290.40 & 438).,3. Gait impairment (781.2).,4. Urinary urgency and incontinence (788.33).,5. Dementia.,6. Hypertension.,7. Hypercholesterolemia." }

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

{ "text_length": 8175 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition." }

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

{ "text_length": 1648 }

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

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

{ "text_length": 7146 }

{ "text": "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." }

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

{ "text_length": 3250 }

{ "text": "PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was performed. The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATION: ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:, None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx. The esophageal mucosa and vascular pattern appeared normal. The lower esophageal sphincter was located at 25 cm from the central incisors. It appeared normal. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which distended with excess air. Rugal folds flattened completely. Gastric mucosa appeared normal throughout. No hiatal hernia was noted. Pyloric valve appeared normal. The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional 2 biopsies were obtained for CLO testing in the antrum. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of procedure well. The patient was turned and the scope was advanced with some difficulty to the terminal ileum. The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted. Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3. The polyp was severed. There was no bleeding at the stalk after removal of the polyp head. The polyp head was removed by suction. Excess air was evacuated from the colon. The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition. Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN: ,Histologic evaluation and CLO testing. I will contact the parents next week with biopsy results and further management plans will be discussed at that time." }

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

{ "text_length": 3027 }

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

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

{ "text_length": 2049 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:, Spinal/epidural with good effect.,FINDINGS: ,Delivered vigorous male infant from cephalic presentation. Apgars 9/9. Birth weight 6 pounds 14 ounces. Infant suctioned with a bulb upon delivery of the head and body. Cord clamped and cut and infant passed to pediatric team present. Complete placenta manually extracted intact with three vessel cord. Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision. In addition, the bladder was involved in adhesion mass complex. A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions. These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall. Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries. Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT: ,Per anesthesia records. Urine cleared postoperatively.,IV FLUIDS: ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia. She was prepped and draped in the usual manner for repeat cesarean section. A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar. This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife. This incision was extended laterally with Mayo scissors. Dense fibromuscular layer was encountered from the patient's previous surgeries. Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision. Fascia was previously separated superiorly and inferiorly from the muscular layer. A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus. Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall. This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall. Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall. These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection. This was successfully done without anterior entry into the bladder. Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus. The uterus was then incised using a sharp knife and low transverse incision. This was extended with bandage scissors. The infant was delivered easily from a cephalic presentation. Bulb suction was done following delivery of the head and body. The cord clamped and cut and the infant passed to pediatric team present. Cord segment and cord blood was obtained. Complete placenta manually extracted intact with three vessel cord. Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces. Complete placenta with three vessels retrieved. Uterus was exteriorized from the abdominal cavity. Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining. Pennington clamps placed at the uterine incision angles and the inferior incision lip. A #1 chromic suture closed the uterus in running continuous interlocking closure. Good hemostasis upon completion of the closure. Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots. The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion. This was closed with chromic suture in a running continuous interlocking closure with good hemostasis. Attention was then focused on the bilateral tubal ligation. Babcock clamp placed in the mid fallopian tube and elevated. Cautery was used to make a window in the avascular segment of the mesosalpinx. Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed. The ligated proximal and distal stumps were then cauterized with Bovie cautery. This tubal ligation procedure was done in a bilateral fashion. Upon completion of tubal ligation, uterus was returned to the abdominal cavity. Left and right gutters examined and found to be clean and dry. Evaluation of the low uterine segment incision revealed continued hemostasis. Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done. Interceed was then placed on the low uterine incision and the low anterior uterine aspect. The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures. Irrigation of the muscular layer with good hemostasis noted. The fascia was closed with #1 Vicryl in a running continuous closure. Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery. The skin was closed with staples." }

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

{ "text_length": 6286 }

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

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

{ "text_length": 2894 }

{ "text": "ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting." }

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

{ "text_length": 2061 }

{ "text": "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." }

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

{ "text_length": 1693 }

{ "text": "PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop. The preparation was good and all surfaces were well seen. The hypopharynx was normal with no evidence of inflammation. The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate. The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's. Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food. The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration. Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation. The scope was withdrawn and the patient was sent to recovery room. She tolerated the procedure well.,FINAL DIAGNOSES:,1. Normal post-gastric bypass anatomy.,2. No evidence of inflammation or narrowing to explain her symptoms." }

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

{ "text_length": 1319 }

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

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

{ "text_length": 5377 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1. Open exploration of the left subclavian/axillary vein.,2. Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy. The left deltopectoral and cervical areas were prepped and draped in the usual fashion. Local anesthetic was infiltrated in the area. There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful. Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic. I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area. I packed the incision and we prepped and redraped the patient including both groins. Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty. The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart. It was done with radiological guidance. Again, I was able to position the catheter in the junction of inferior vena cava and right atrium. The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area. The port had been aspirated satisfactorily and irrigated with heparin solution. The drain incision was closed in layers including subcuticular suture with Monocryl. Then, we went up to the left shoulder and closed that incision in layers. Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition." }

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

{ "text_length": 2173 }

{ "text": "PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room." }

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

{ "text_length": 2990 }

{ "text": "PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS: ,1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.,2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.,3. The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1. Left ventricular dysfunction with ejection fraction of 10% to 15%.,2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN: ,1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2. Hydration.,3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis." }

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

{ "text_length": 6138 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION: ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes. The patient was stabilized from cardiac standpoint on a renal ultrasound. The patient was found to have a bladder mass. The patient does have a history of bladder cancer. Options were watchful waiting, resection of the bladder tumor were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed. The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR: ,The patient was brought to the OR, anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 23-French scope was inserted inside the urethra into the bladder. The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________. There was a periureteral diverticulum, lateral to the left ureteral opening. There were moderate trabeculations throughout the bladder. There were no stones. Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal. Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base. Deep biopsies were sent separately. Coagulation was performed around the periphery and at the base of the tumor. All the tumors were removed and sent for path analysis. There was an excellent hemostasis. The rest of the bladder appeared normal. There was no further evidence of tumor. At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition." }

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

{ "text_length": 2085 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL." }

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

{ "text_length": 5786 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-c4 and C4-C5.,2. Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-C4 and C4-C5.,2. Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1. Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2. Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3. Anterior cervical fusion, C3-C4 (CPT 22554),4. Anterior cervical fusion, C4-C5 (CPT 22585).,5. Utilization of allograft for purposes of spinal fusion (CPT 20931).,6. Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE INDICATIONS: ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. We discussed the diagnosis and the treatment options. Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5. We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. Furthermore I explained that the fusion may not become solid or that the hardware could break. We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation. I explained the rationale for this as well as the options of using his own bone. Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. He was then positioned supine on the operating table, and all bony prominences were padded. Pulse oximetry was maintained on both feet throughout the case. The arms were carefully padded and tucked at his sides. A roll was placed between the shoulder blades. The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. Ten pounds of traction was applied. A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle. This was then split in line with its fibers. Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. A needle was placed into a disc and an x-ray was done to determine its location. The longus colli muscles were then elevated bilaterally with the electrocautery unit. Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5. This included complete removal of the anterior annulus, nucleus, and posterior annulus. The posterior longitudinal ligament was removed as were the posterior osteophytes. Foraminotomies were then accomplished bilaterally. Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace. Bleeding cancellous bone was exposed. The disc spaces were measured and appropriate size allografts were placed sterilely onto the field. After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. Two screws were then placed into each of the vertebral bodies at C3, C4, and C5. There was excellent purchase. A final x-ray was done confirming good position of the hardware and grafts. The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks. The carotid pulse was strong. A drain was placed deep to the level of the platysma muscle and left at the level of the hardware. The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure. Steri-Strips were placed followed by application of a sterile dressing. The drain was hooked to bulb suction. A Philadelphia collar was applied.,The cranial tongs were carefully removed. The soft tissue overlying the puncture site was massaged to free it up from the underlying bone. There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well." }

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

{ "text_length": 6187 }

{ "text": "REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress. ,PROCEDURE: ,I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed.," }

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

{ "text_length": 1285 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week." }

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

{ "text_length": 3341 }

{ "text": "A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and replaced with the laparoscope. A 1 cm suprapubic skin incision was made. Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope. The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis. Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal. The probe was withdrawn and replaced with the bipolar cautery instrument. The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus. Electrical current was applied to the tube at this point and fulgurated. The tube was then regrasped just distal to this and refulgurated. It was then regrasped just distal to the lateral point and refulgurated again. The same procedure was then carried out on the opposite tube. The bipolar cautery instrument was withdrawn and replaced with the probe. The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes. The upper abdomen was visualized, and the liver surface was normal. The gas was allowed to escape from the abdomen, and the instruments were removed. The skin incisions were repaired. The instruments were removed from the vagina.,There were no complications to the procedure. Blood loss was minimal. The patient went to the postanesthesia recovery room in stable condition." }

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

{ "text_length": 1780 }

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

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

{ "text_length": 1703 }

{ "text": "DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement." }

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

{ "text_length": 3803 }

{ "text": "FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV." }

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

{ "text_length": 2796 }

{ "text": "HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months." }

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

{ "text_length": 3416 }

{ "text": "PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:, Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED: ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,20 mL.,TUBES/DRAINS: ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: ,The patient is a 17-month-old boy with hypospadias abnormality. The plan is for repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. IV antibiotics were given. He was then placed in the supine position. The foreskin was retracted and cleansed. He was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed on the glans. The urethra was calibrated with the lacrimal duct probes to an 8-French. We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff. We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis. The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap. Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection. He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck. We repeated the artificial erection and the penis was straight. We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. Using the curved iris scissors, we then also further mobilized the glanular wings. The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate. The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter. We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl. We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well. 5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans. Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans. Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place. IV Toradol was given at the procedure. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room." }

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

{ "text_length": 3830 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:, Sterilization candidate.,PROCEDURE PERFORMED:,1. Cervical dilatation.,2. Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:, This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile. There are no adnexal masses appreciated. On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal. The liver margin and bowel appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room where general anesthetic was administered. The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators. A #20 Hank dilator was left in place. The sterile speculum was then removed. Gloves were changed. Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar. The Veress needle was placed and gas was turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted. Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus. The Endoloop was placed through the left-sided port. A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper. A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube. The suture was then cut using the endoscopic shears. The portion of tube that was tied off was removed using a Harmonic scalpel. This was then removed from the abdomen and sent to Pathology. The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop. The loop was then synched down. The Endoshears were used to cut the suture. The Harmonic scalpel was then used to remove that portion of tube. The portion of the tube that was removed from the abdomen was sent to Pathology. Both tubes were examined and found to have excellent hemostasis. All instruments were then removed. The 5 mm ports were removed with good hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar was removed. The fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of Marcaine was injected at the incision site. The vulsellum tenaculum and cervical dilator were then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition. She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks." }

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

{ "text_length": 3833 }

{ "text": "PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type." }

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

{ "text_length": 3967 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:, Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer. She was counseled to undergo laparoscopic staging.,FINDINGS:, During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries. No ascites was present. On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered. She was placed in a low anterior lithotomy position using Allen stirrups. The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine. There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports. The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty. The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed. There were no adhesions underlying the previous vertical midline scar. The 10-mm port was placed in the umbilicus, and the laparoscope was inserted. Remaining ports were placed under direct laparoscopic guidance. Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy. An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum. The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached. Pedicles were sealed and divided with bipolar cutting forceps. Excellent hemostasis was noted. Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery. Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps. The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially. The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally. The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy. The right infundibulopelvic ligament was divided using the bipolar cutting forceps. The mesovarium was skeletonized. A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder. Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring. The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries. The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum. The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device. The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen. The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture. The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released. The umbilical port was removed using laparoscopic guidance. The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl. The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened and taken to the post anesthesia care unit in stable condition." }

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

{ "text_length": 5167 }

{ "text": "PREOPERATIVE DIAGNOSES: , Bladder laceration.,POSTOPERATIVE DIAGNOSES:, Bladder laceration.,NAME OF OPERATION: , Closure of bladder laceration.,FINDINGS:, The patient was undergoing a cesarean section for twins. During the course of the procedure, a bladder laceration was notices and urology was consulted. Findings were a laceration on the dome of the bladder.,PROCEDURE: , Initially there as a mucosal layer of suture already placed. This was done with 3-0 chromic catgut. The bladder was distended and, while the bladder was distended with physiologic saline, a second layer of 3-0 chromic catgut created a watertight closure. The second layer included the mucosa an dinner layer of the detrusor muscle. A third layer of 2-0 Dexon was used. Each of these were placed in a continuous running-locked suture technique. There was complete watertight closure of the bladder. Hemostasis was assured and a Jackson-Pratt drain was brought out through a separate stab wound. The remaining portion of the operation, both the cesarean section and the wound closure, will be dictated by Dr. Redmond." }

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

{ "text_length": 1103 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:, Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable. Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst. The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow. I saw the patient in my clinic. I explained to the mother in Spanish the risk and benefits. Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery. We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. A prophylactic dose of antibiotic was given. The patient was prepped and draped in a usual manner. The procedure began by infiltrating lidocaine with epinephrine around the cyst area. Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point. The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst. The cyst was detached of the surrounding structure with the help of blunt dissection. Hemostasis was achieved with electrocautery. The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond. The patient tolerated the procedure well without complications and transferred to recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure." }

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

{ "text_length": 1922 }

{ "text": "EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS: ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal Doppler blood flow. The left epididymis has an unremarkable appearance. There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm. The epididymis has normal appearance. There is a trace hydrocele. No intratesticular masses or torsion is identified. There is no significant scrotal wall thickening.,IMPRESSION: ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination." }

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

{ "text_length": 741 }

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

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

{ "text_length": 3217 }

{ "text": "REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant. Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction. The urinary bladder is normal. The uterus appears unremarkable. Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen. The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis." }

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

{ "text_length": 784 }

{ "text": "PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated." }

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

{ "text_length": 4520 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site. He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision. The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand. He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position. The wound was copiously irrigated with normal saline on irrigating tip. After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion. The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used. We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon. The wound came together very nicely. Tincture of Benzoin was placed. Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips. The patient tolerated the procedure well with no complications." }

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

{ "text_length": 2058 }

{ "text": "PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position. The patient was prepped and draped in a sterile manner. The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter. This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle. A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle. The needle was withdrawn. The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak. The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure. The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene. Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created. Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery. A pocket was created that would encompass the SynchroMed fusion pump. A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device. The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision. The intrathecal catheter was trimmed. A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together. The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties. Good CSF was then demonstrated flowing through the SynchroMed pump catheter. The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie. Excess catheter was coiled and placed behind the pump. The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall. The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed. The subcutaneous tissues were irrigated with normal saline. The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl. The skin of both wounds was closed with staples. Antibiotic ointment and a sterile dressing were applied. The patient was awake and taken to the recovery room. The patient tolerated the procedure well and was stable at the completion of the procedure. All sponge and lap, needle and instrument counts were correct at the completion of the procedure." }

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

{ "text_length": 3501 }

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

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

{ "text_length": 1658 }

{ "text": "S -, An 84-year-old diabetic female, 5'7-1/2\" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.," }

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

{ "text_length": 1247 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease." }

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

{ "text_length": 4653 }

{ "text": "EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:, Ureteral stricture.,AP ABDOMEN ,FINDINGS:, Comparison is made to study from Month DD, YYYY. There is a left lower quadrant ostomy. There are no dilated bowel loops suggesting obstruction. There is a double-J right ureteral stent, which appears in place. There are several pelvic calcifications, which are likely vascular. No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters. Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent. No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:, The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm. There is a right renal/ureteral stent identified. There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis. No stone or solid masses seen. The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1. Left-sided hydronephrosis.,2. No visible renal or ureteral calculi.,3. Right ureteral stent." }

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

{ "text_length": 1180 }

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

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

{ "text_length": 3425 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED: ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease. Upon endoscopy, the colon prep was good. We were able to reach the cecum without difficulty. There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions. There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm. This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE: ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position. IV sedation was given by Anesthesia Department. The Olympus videoscope was inserted into anus. Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted. The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel. When the polyp again was visualized, the snare was passed around the polyp. It required at least two to three passes of the snare to remove the polyp in its totality. There was a large stalk on the polyp. ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present. No bleeding was identified. The colonoscope was then removed and patient was sent to recovery room in stable condition." }

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

{ "text_length": 1680 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination." }

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

{ "text_length": 1709 }

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

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

{ "text_length": 991 }

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

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

{ "text_length": 3019 }

{ "text": "The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE: ,The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed. Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff. He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect. Bilateral groins had been prepped and draped in the usual fashion. Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle. All catheters were passed using a J-tipped guide-wire. Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter. Left system coronary angiography performed using a 6-French JL4 catheter. Right system coronary angiography performed using a 6-French CDRC catheter. Following the procedure, all catheters were removed. Manual pressure was held with the Neptune pad and the patient was discharged back to his room. I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses. There were no apparent complications. A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1. Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2. The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3. The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4. The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity. There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1. Mild to moderate left main stenosis.,2. Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin. We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high." }

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

{ "text_length": 3081 }

{ "text": "SUBJECTIVE:, She is here for a followup on her weight loss on phentermine. She has gained another pound since she was here last. We talked at length about the continued plateau she has had with her weight. She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136. She is frustrated with this as well. We agree that if she continues to plateau she really should not stay on phentermine. We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.,REVIEW OF SYSTEMS:, Otherwise negative. She has no specific complaints. No shortness of breath, chest pain or palpitations.,PHYSICAL EXAM:,Vital signs: Her blood pressure is fine. Her diastolic is a little bit high, but otherwise okay.,General: She appears in good spirits. No apparent distress.,HEENT: Negative.,Neck: Supple without bruits.,Chest: Clear.,Cardiac exam: Regular without extra sounds.,ASSESSMENT:, Weight loss on phentermine, really has plateaued.,PLAN:, If she does not lose weight in the next month we will probably consider having her go off the phentermine. If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop. She agrees with this plan." }

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

{ "text_length": 1435 }

{ "text": "SUMMARY OF CLINICAL HISTORY:, The patient was a 35-year-old African-American male with no significant past medical history who called EMS with shortness of breath and chest pain. Upon EMS arrival, patient was tachypneic at 40 breaths per minute with oxygen saturation of 90%. At the scene, EMS administered breathing treatments and checked lung sounds that did not reveal any evidence of fluid in the lung fields. EMS also reports patient was agitated upon their arrival at his residence. Two minutes after arrival at UTMB at 1500, the patient became unresponsive, apneic, and had oxygen saturations from 80-90%. The patient's heart rate decreased to asystole, was intubated with good breath sounds and air movement. Patient then had wide complex bradycardia and ACLS protocol for pulseless electrical activity was followed for 45 minutes. The patient was administered TPA with no improvement. Bedside echocardiogram showed no pericardial effusion. The patient was administered D5W, Narcan, and multiple rounds of epinephrine and atropine, calcium chloride, and sodium bicarbonate. The patient had three episodes of ventricular tachycardia/fibrillation with cardioversion/defibrillation resulting in asystole. The patient was pronounced dead at 1605 with fixed, dilated pupils, no heart sounds, no pulse and no spontaneous respirations.,DESCRIPTION OF GROSS LESIONS,EXTERNAL EXAMINATION:, The body is that of a 35-year-old well-developed, well-nourished male. There is no peripheral edema of the extremities. There is an area of congestion/erythema on the upper chest and anterior neck. There are multiple small areas of hemorrhage bilaterally in the conjunctiva. A nasogastric tube and endotracheal tube are in place. There is an intravenous line in the right hand and left femoral region. The patient has multiple lead pads on the thorax. The patient has no other major surgical scars.,INTERNAL EXAMINATION (BODY CAVITIES):, The right and left pleural cavity contains 10 ml of clear fluid with no adhesions. The pericardial sac is yellow, glistening without adhesions or fibrosis and contains 30 ml of a straw colored fluid. There is minimal fluid in the peritoneal cavity.,HEART:, The heart is large with a normal shape and a weight of 400 grams. The pericardium is intact. The epicardial fat is diffusely firm. As patient was greater than 48 hours post mortem, no TTC staining was utilized. Upon opening the heart was grossly normal without evidence of infarction. There were slightly raised white plaques in the left ventricle wall lining. The left ventricle measures 2.2 cm, the right ventricle measures 0.2 cm, the tricuspid ring measures 11 cm, the pulmonic right measures 8 cm, the mitral ring measures 10.2 cm, and the aortic ring measures 7 cm. The foramen ovale is closed. The circulation is left dominant. Examination of the great vessels of the heart reveals minimal atherosclerosis with the area of greatest stenosis (20% stenosis) at the bifurcation of the LAD.,AORTA:, There is minimal atherosclerosis with no measurable plaques along the full length of the ascending and descending aorta.,LUNGS: , The right lung weighed 630 grams, the left weighed 710 grams. The lung parenchyma is pink without evidence of congestion of hemorrhage. The bronchi are grossly normal. In the right lung, there are two large organizing thrombo-emboli. The first is located at the first branch of the pulmonary artery with an older, organizing area adherent to the vessel wall measuring 1.0 x 1.0 x 2.5 cm. Surrounding this organizing area is a newer area of apparent thrombosis completely occluding the bifurcation. The other large organizing, adherent embolus is located further in out in the vasculature measuring approximately 1.0 x 1.0 x 1.5 cm. There are multiple other emboli located in smaller pulmonary vessels that show evidence of distending the vessels they are located inside.,GASTROINTESTINAL SYSTEM:, The esophagus and stomach are normal in appearance without evidence of ulcers or varices. The stomach contains approximately 800 ml, without evidence of any pills or other non-foodstuff material. The pancreas shows a normal lobular cut surface with evidence of autolysis. The duodenum, ileum, jejunum and colon are all grossly normal without evidence of abnormal vasculature or diverticula. An appendix is present and is unremarkable. The liver weighs 2850 grams and the cut surface reveals a normal liver with no fibrosis present grossly. The gallbladder is in place with a probe patent bile duct through to the ampulla of Vater.,RETICULOENDOTHELIAL SYSTEM:, The spleen is large weighing 340 grams, the cut surface reveals a normal appearing white and red pulp. No abnormally large lymph nodes were noted.,GENITOURINARY SYSTEM:, The right kidney weighs 200 grams, the left weighs 210 grams. The left kidney contains a 1.0 x 1.0 x 1.0 simple cyst containing a clear fluid. The cut surface reveals a normal appearing cortex and medulla with intact calyces. The prostate and seminal vessels were cut revealing normal appearing prostate and seminal vesicle tissue without evidence of inflammation or embolus.,ENDOCRINE SYSTEM:, The adrenal glands are in the normal position and weigh 8.0 grams on the right and 11.6 grams on the left. The cut surface of the adrenal glands reveals a normal appearing cortex and medulla. The thyroid gland weighs 12.4 grams and is grossly normal.,EXTREMITIES:, Both legs and calves were measured and found to be very similar in circumference. Both legs were also milked and produced no clots in the venous system.,CLINICOPATHOLOGIC CORRELATION,This patient died shortly after a previous pulmonary embolus completely occluded the right pulmonary artery vasculature., ,The most significant finding on autopsy was the presence of multiple old and new thromboemboli in the pulmonary vasculature of the right lung. The autopsy revealed evidence of multiple emboli in the right lung that were at least a few days old because the emboli that were organizing were adherent to the vessel wall. In order to be adherent to the vessel wall, the emboli must be in place long enough to evoke a fibroblast response, which takes at least a few days. The fatal event was not the old emboli in the right lung, but rather the thrombosis on top of the large saddle thrombus residing in the pulmonary artery. This created a high-pressure situation that the right ventricle could not handle resulting in cardiac dysfunction and ultimately the patient's demise.,Although this case is fairly straight forward in terms of what caused the terminal event, perhaps the more interesting question is why a relatively healthy 35-year-old man would develop a fatal pulmonary embolism. Virchow's triad suggests we should investigate endothelial injury, stasis and a hypercoagulable state as possible etiologies. The age of the patient probably precludes venous stasis as the sole reason for the embolus although it could have certainly contributed. The autopsy revealed no evidence of endothelial damage in the pulmonary vasculature that would have caused the occlusion. The next logical reason would be a hypercoagulable state. Some possibilities include obesity, trauma, surgery, cancer, Factor V Leiden deficiency (as well as other inherited disorders-prothrombin gene mutation, deficiencies in protein C, protein S, or antithrombin III, and disorders of plasminogen), and Lupus anticoagulant. Of these risks factors, obesity was the only risk factor the patient was known to have. The patient had no evidence of trauma, surgery, cancer or the stigmata of SLE, therefore these are unlikely. Perhaps the most fruitful search would be an examination of the genetic possibilities for a hypercoagulable state (Factor V Leiden being the most common).,In summary, this patient died of a pulmonary embolism, the underlying cause of which is currently undetermined. A definitive diagnosis may be ascertained with either genetic or other laboratory tests and a more detailed history.,SUMMARY AND REFLECTION,WHAT I LEARNED FROM THIS AUTOPSY:, I learned that although a cause of death may sometimes be obvious, the underlying mechanism for the death may still be elusive. This patient was an otherwise completely healthy 35-year-old man with one known risk factor for a hypercoagulable state.,REMAINING UNANSWERED QUESTIONS:, Basically the cause of the hypercoagulable state is undetermined. Once that question is answered I believe this autopsy will have done a great service for the patient's family." }

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

{ "text_length": 8579 }

{ "text": "REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours. However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion. She had also complained of blurred vision for several days. She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet. ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS: ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies. CBC was normal, aside from a hemoglobin of 11.2. ECG showed atrial fibrillation. BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented. She has some impairment of recent memory. She is not dysphasic, or apraxic. Speech is normal and clear. The head is noted to be normocephalic. Neck is supple. Carotid pulses are full bilaterally, with left carotid bruit. Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold. Motor examination shows no drift of the outstretched arms. There is no tremor or past-pointing. Finger-to-nose and heel-to-shin performed well bilaterally. Motor showed intact neuromuscular tone, strength, and coordination in all limbs. Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout. Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit. She also has atrial fibrillation, apparently chronic. In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:, I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy. In view of her age, I would be reluctant to recommend Coumadin anticoagulation. I will be happy to follow the patient with you." }

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

{ "text_length": 2678 }

{ "text": "HISTORY OF PRESENT ILLNESS: ,I have seen ABC today for her preoperative visit for weight management. I have explained to her the need for Optifast for weight loss prior to these procedures to make it safer because of the large size of her liver. She understands this.,IMPRESSION/PLAN:, We are going to put her on two weeks of Optifast at around 900 calories. I have also explained the risks and potential complications of laparoscopic cholecystectomy to her in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, injury to the small intestine, stomach, liver, leak from the cystic duct, common bile duct, and possible need for ERCP and further surgery. This surgery is going to be planned for October 6. This is for cholelithiasis prior to her Lap-Banding procedure.,I have also reviewed with her the risks and potential complications of laparoscopic gastric banding including bleeding, infection, deep venous thrombosis, pulmonary embolism, slippage of the band, erosion of the band, injury to the esophagus, stomach, small intestine, large intestine, spleen, liver, injury to the band, port, or tubing necessitating replacement of the band, port, or tubing among other potential complications and she understands. We are going to proceed for laparoscopic gastric banding. I have reviewed her entire chart in detail. I have also gone over with her the Fairfield County Bariatrics consent form for banding and all the risks. She has also signed the St. Vincent's Hospital consent form for Lap-Banding. She has taken the preoperative quiz for banding. She has signed the preop and postop instructions, and understands them and we reviewed them. She has taken the quiz and done fairly well. We have reviewed with her any potential other issues and I have answered her questions. She is planned for surgical intervention.," }

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

{ "text_length": 1863 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:, Left thyroid mass.,PROCEDURE PERFORMED:, Left total thyroid lumpectomy.,ANESTHESIA,: General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE:, The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE: ,The patient is brought to the operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. After this, the skin incision was marked approximately two fingerbreadths above the sternal notch. It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. After this, the midline was then identified and grasped on either side with a DeBakey forceps. The raphe was noted and Bovie cauterization was utilized to cut down into this region. The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. It was separated on the left side from the patient's sternothyroid muscle. After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors. Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners. After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. It was freed from the thyroid gland and reflected laterally and posteriorly. The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed. The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors. The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie. The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut. Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition. The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards." }

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

{ "text_length": 4885 }

{ "text": "HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE: ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.," }

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

{ "text_length": 4588 }

{ "text": "HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.," }

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

{ "text_length": 8208 }

{ "text": "PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:, Bilateral chronic otitis media,ANESTHESIA:, General mask,NAME OF OPERATION:, Bilateral Myringotomy with placement of PE tubes,PROCEDURE:, The patient was taken to the operating room and placed in the supine position. After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case. First, the left and then the right tympanic membrane, was approached. An anterior-inferior radial incision was made in the left tympanic membrane. Suction revealed a substantial amount of mucopurulent drainage. A Sheehy pressure equalization tube was placed in the myringotomy site. Floxin drops were added. The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition." }

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

{ "text_length": 963 }

{ "text": "TITLE OF OPERATION:, Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:, Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:, Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding. The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping. Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles. The patient also had a right subtemporal depression, which was full preoperatively. The entire old apparatus was dissected out. We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted. They were both inspected. No definite debris were seen. After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter. On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location. The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture. The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir. All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips. The patient tolerated the procedure well without complications. CSF was not sent off." }

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

{ "text_length": 3008 }

{ "text": "PAST MEDICAL HISTORY: ,She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:, Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:, She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval." }

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

{ "text_length": 1763 }

{ "text": "Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation. She is suffering from ongoing myofascitis. Her treatment plan will consist of a series of trigger point injections, which were performed today. She tolerated the procedure well. I have asked her to ice the region intermittently for 15 minutes off and on x 3. She will be followed in four weeks' time for repeat trigger point injections if indicated.," }

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

{ "text_length": 758 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1. Urinary hesitancy and weak stream.,2. Urethral narrowing.,3. Mild posterior wall erythema.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Urethral dilation.,3. Bladder biopsy and fulguration.,ANESTHESIA: ,General.,SPECIMEN: ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:, Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French. A midureteral polyp was noted. Cystoscopy revealed multiple cellules and mild trabeculation of the bladder. Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa. No obvious raised bladder tumor was noted. No foreign bodies were noted. The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope. Cystoscopy was performed in its entirety with the above findings. The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area. The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined. No evidence of active bleeding noted. The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks. She is given prescription for Levaquin and Pyridium and given discharge instructions." }

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

{ "text_length": 2087 }

{ "text": "CHIEF COMPLAINT:, Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand." }

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

{ "text_length": 1260 }

{ "text": "REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting." }

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

{ "text_length": 1209 }

{ "text": "HISTORY: ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain. This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue. This numbness has been present for approximately two months. It seems to be there \"all the time.\" He was seen by his dentist and after dental evaluation was noted to be \"okay.\" He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time. He has been taking cough drops and trying to increase his fluids. He has recently stopped tobacco. He has been chewing tobacco for about 30 years. Again, there is concern regarding the numbness he has been having. He has had a loss of sensation of taste as well. Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip. He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity. He has had no trauma to the face. He does note a history of headaches. These are occasional and he gets these within the neck area when they do flare up. The headaches are noted to be less than one or two times per month. The patient does note he has a history of anxiety disorder as well. He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time. He denies any fever or chills. He is not having any dental pain with biting down. He has had no jaw popping and no trismus noted. The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:, Tylenol. He is on Nicorette gum.,ALLERGIES: ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY: ,The patient is single, self-employed carpenter. He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL: The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Both ears, external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. He does have moderate tympanosclerosis noted, no erythema. Weber exam is midline. Hearing is grossly intact and normal.,NASAL: Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: He does have slightly decreased sensation to the left jaw. He is able to feel pressure on touch. This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed. See separate operative report in chart. This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION: ,1. Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2. History of tobacco use.,3. Hypogeusia with loss of taste.,4. Headaches.,5. Xerostomia.,RECOMMENDATIONS:, I have ordered a CT of the head. This includes sinuses and mandible. This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had. On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted. I did recommend he increase his fluid intake. He is to remain off the tobacco. I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time." }

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

{ "text_length": 5120 }

{ "text": "DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.,The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.,3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems." }

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

{ "text_length": 3132 }

{ "text": "CHIEF COMPLAINT:, Cut on foot.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.,PAST MEDICAL HISTORY:, Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient appears to be healthy. The patient is calm and comfortable in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:, The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1. A 4-MM LACERATION TO THE RIGHT FOOT.,2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on." }

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

{ "text_length": 3398 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1. Colovesical fistula.,2. Intraperitoneal abscess.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Low anterior colon resection.,3. Flexible colonoscopy.,4. Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY: ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra. The patient had retrograde cystogram, which revealed colovesical fistula. Recommendation for a surgery was made. The patient was explained the risks and benefits as well as the two sons and the daughter. They understood that the patient can even die from this procedure. All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic. An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker. Electrocautery was used for hemostasis down to the fascia. The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall. At this point, immediately a small bowel was retracted cephalad. The patient was taken to a slightly Trendelenburg position and the descending colon was seen. The white line of Toldt was opened all the way down to the area of inflammation. At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess. When the small bowel was completely freed of abscess, bulk of the bladder was seen anteriorly to the uterus. The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized. At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum. At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed. Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired. The specimen was cut with #10 blade Bard-Parker and sent it to Pathology. Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis. A pursestring device was fired. The staple line was cut. The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied. At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced. The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient. ,Immediately, the EEA was connected with a mushroom. It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches. Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air. No air was seen evolving from the staple line. All fluid was removed and pictures of the staple line were taken. The scope was removed at this point. The case was passed to Dr. X for repair of the vesicle fistula. Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon. After this was performed, copious amount of irrigation was used again. More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area. The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin. The wire was passed under the transverse colon. It was left in place. Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis. At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied. Electrocautery for hemostasis and the subcutaneous tissue. Copious amount of irrigation was used. The skin was approximated with staples. At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made. The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge. One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened. As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture. The JP was secured with #3-0 nylon suture as well. At this point, dressings were applied. The patient tolerated the procedure well. The stent from the left ureter was removed and the Foley was left in place. The patient did tolerate the procedure well and will be followed up during the hospitalization." }

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

{ "text_length": 6117 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital." }

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

{ "text_length": 4329 }

{ "text": "OPERATIVE PROCEDURE:,1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2. Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed. Chest, abdomen an legs were prepped and draped in sterile fashion. The femoral artery on the right was punctured and a guidewire was placed. The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution. The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened. The wires were cut and removed. The sternum was divided in the midline. Retrosternal attachments were taken down. The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The heart was dissected free of its adhesions. The patient was fully heparinized and cannulated with a single aorta and single venous cannula. Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene. An antegrade cardioplegia needle sump was placed and secured to the ascending aorta. Cardiopulmonary bypass ensued. The ascending aorta was cross clamped. Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg. It was followed by sumping the ascending aorta. The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given, a total of 200 cc. The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given. The mammary was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given. The cross clamp was removed. A partial-occlusion clamp was placed. Aortotomies were made. The vein was cut to fit these and sutured in place with running 5-0 Prolene suture. The partial-occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. The patient was fully warmed and ventilation was commenced. The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire. The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well." }

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

{ "text_length": 3744 }

{ "text": "PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:, This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped. Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition." }

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

{ "text_length": 1769 }

{ "text": "DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated. Membranes ruptured this morning by me with some meconium. An IUPC was placed. Some Pitocin was started because the contractions were very weak. She progressed in labor throughout the day. Finally getting the complete at around 1530 hours and began pushing. Pushed for about an hour and a half when she was starting to crown. The Foley was already removed at some point during the pushing. The epidural was turned down by the anesthesiologist because she was totally numb. She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping. She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed. With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance. Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly. The placenta separated with some bleeding seen and was assisted expressed and completely intact. Uterus firmed up well with IV pit. Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural. Once this was complete, mom and baby doing well. Baby was a female infant. Apgars 8 and 9." }

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

{ "text_length": 1794 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week." }

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

{ "text_length": 4700 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1. Protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,3. Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service. She has been hospitalized multiple times for intractable nausea and vomiting and dehydration. She states that her decreased p.o. intake has been progressively worsening. She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room. She was placed in the supine position. The area was prepped and draped in the sterile fashion. After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed. The esophagus, stomach, and duodenum were visualized without difficulty. There was no gross evidence of any malignancy. There was some enterogastritis which was noted upon exam. The appropriate location was noted on the anterior wall of the stomach. This area was localized externally with 1% lidocaine. Large gauge needle was used to enter the lumen of the stomach under visualization. A guide wire was then passed again under visualization and the needle was subsequently removed. A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well. A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty. The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach. The balloon was then insufflated and the break-away sheath was then pulled away. Proper placement of the tube was ensured through visualization with a scope. The tube was then sutured into place using nylon suture. Appropriate sterile dressing was applied.,DISPOSITION: ,The patient was transferred to the recovery in a stable condition. She was subsequently returned to her room on the General Medical Floor. Previous orders will be resumed. We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings." }

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

{ "text_length": 2790 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation." }

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

{ "text_length": 1119 }

{ "text": "CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:, None.,MEDICATIONS:, None.,FAMILY HISTORY:, Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:, None.,SOCIAL HISTORY: , The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:, The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia." }

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

{ "text_length": 1528 }

{ "text": "IMPRESSION: ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity." }

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

{ "text_length": 154 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE: ,The patient had marks and measurements prior to surgery. Additional marks and measurements were made at the time of surgery; these were again checked. At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine. Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed. The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract. The eyes were kept irrigated and protected throughout the procedure. Attention was turned to the opposite side. Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips. Attention was turned to the right lower lid. A lash line incision was made. A skin flap was elevated and the muscle was opened. Large herniated adipose tissue pads were present in each of the three compartments. They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised. Attention was turned to he opposite side. The procedure was carried out as just described. The contralateral side was reexamined and irrigated. Hemostasis was good and it was closed with a running 6-0 Prolene. The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied. The eyes were again irrigated and cool Swiss Eye compresses applied. At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room." }

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

{ "text_length": 2135 }

{ "text": "HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers." }

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

{ "text_length": 5525 }

{ "text": "PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:, No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.,ASSESSMENT AND PLAN:, This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case." }

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

{ "text_length": 2746 }

{ "text": "CHIEF COMPLAINT:, Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anything, and has vomited 8 times. AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:, AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and \"crack chest pain\" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:, None.,ALLERGIES:, Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, AF was born and raised in San Francisco. His father was an alcoholic. He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:, AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs: T: 37.1" }

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

{ "text_length": 1779 }

{ "text": "REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:," }

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

{ "text_length": 92 }

{ "text": "PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well." }

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

{ "text_length": 950 }

{ "text": "REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY: ,Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES: ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS: ,The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:" }

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

{ "text_length": 2974 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management. All risks and benefits were explained. Questions answered. Options discussed. No guarantees were made. She wished to proceed with surgery.,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. Bipolar electrocautery was used to maintain meticulous hemostasis. I then performed an antebrachial fasciotomy proximally. I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. Great care was taken with placement. A good plane was positively identified. I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me. I had my thumb on the distal aspect of the transverse carpal ligament. I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. I pulled back and cut and partially tightened the transverse carpal ligament. I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. I then checked to make sure this was properly performed and then cut the proximal aspect. I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time. Great care was taken and at no point was there any longitudinal structure cut. Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut. Following this, I irrigated and closed the skin. The patient was dressed and sent to the recovery room in good condition." }

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

{ "text_length": 2659 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with" }

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

{ "text_length": 4311 }

{ "text": "CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:" }

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

{ "text_length": 1535 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1. Hiatal hernia.,2. Reflux esophagitis.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:, Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:, The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough. She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated. At the GE junction, a hiatal hernia was present. There were mild inflammatory changes consistent with reflux esophagitis. The scope was then passed into the stomach. It was insufflated and the scope was coursed along the greater curvature to the antrum. The pylorus was patent. There was evidence of bile reflux in the antrum. The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation. The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized. The gastroscope was then slowly withdrawn. There were no other abnormalities noted in the fundus or body. Once again at the GE junction, esophageal biopsy was taken. The scope was then completely withdrawn. The patient tolerated the procedure and was transferred to the recovery room in stable condition. She will return to the General Medical Floor. We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions. She should also attempt significant weight loss." }

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

{ "text_length": 2059 }

{ "text": "CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY: ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock. Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: This is an overweight African-American female not in any distress.,VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range.,HEENT: Normal to inspection.,NECK: No bruits or adenopathy.,LUNGS: Clear to auscultation.,CV: Regular rate and rhythm.,ABDOMEN: Protuberant, soft, and nontender.,EXTREMITIES: No clubbing, cyanosis or edema.,RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details." }

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

{ "text_length": 1802 }

{ "text": "SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.,CHEST: There is prolonged expiration.,CARDIOVASCULAR: First and second heart sounds are heard. No murmur was appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive.,EXTREMITIES: He has 2+ pedal swelling.,NEUROLOGIC: The patient is asleep, but easily arousable.,LABORATORY DATA:, PTT is 49. INR is pending. BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8. AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia. Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1. Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. Continue current treatment as per Cardiology. We will consider adding ACE inhibitors as renal function improves.,2. Acute pulmonary edema, resolved.,3. Rapid atrial fibrillation, rate controlled. The patient is on beta-blockers and digoxin. Continue Coumadin. Monitor INR.,4. Coronary artery disease with ischemic cardiomyopathy. Continue beta-blockers.,5. Urinary tract infection. Continue Rocephin.,6. Bilateral perfusion secondary to congestive heart failure. We will monitor.,7. Chronic obstructive pulmonary disease, stable.,8. Abnormal liver function due to congestive heart failure with liver congestion, improving.,9. Rule out hypercholesterolemia. We will check lipid profile.,10. Tobacco smoking disorder. The patient has been counseled.,11. Hyponatremia, stable. This is due to fluid overload. Continue diuresis as per Nephrology.,12. Deep venous thrombosis prophylaxis. The patient is on heparin drip." }

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

{ "text_length": 1903 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1. Gallbladder.,2. Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:, Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. Additionally, there was a notable liver cyst. The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy. The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods. She had had multiple attacks in the past of these complaints. She was discovered to have had right upper quadrant pain on examination. Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis. The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms. She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE: ,The patient was brought to the operative suite and placed in the supine position. The patient received preoperative antibiotics with Kefzol. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient did undergo general endotracheal anesthesia. Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel. Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation. The abdomen was insufflated to 15 mmHg. After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder. Decision to proceed with laparoscopic cystectomy was decided. A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen. Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin. All ports were inserted with bladed 5 mm trocar then under direct visualization. After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder. Adhesions adjacent were taken down with a Maryland dissector. Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly. This helped to better delineate the cystic duct as well as the cystic artery. Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one. Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally. Utilizing endoscissors, the cystic duct and cystic artery were ligated. Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed. Electrocautery was used to stop any bleeding encountered along the way. The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen. No evidence of stones were visualized. Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port. This was sent off as an specimen, a gallstone was identified within the gallbladder. Next, utilizing copious amounts of irrigation, the abdomen was irrigated. A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver. This was also taken and sent off as specimen. The abdomen was then copiously irrigated until clear irrigation was identified. All laparoscopic ports were removed under direct visualization. The abdomen was de-insufflated. Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region. All incisions were then closed with #4-0 undyed Vicryl. Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures. The areas were cleaned and dried. Steri-Strips were placed. On the incisions, sterile dressing was applied. The patient tolerated the procedure well. She was extubated following procedure. She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation." }

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

{ "text_length": 5065 }

{ "text": "PREOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,PROCEDURES: ,1. Left calcaneal lengthening osteotomy with allograft.,2. Partial plantar fasciotomy.,3. Posterior subtalar and tibiotalar capsulotomy.,4. Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age. Since that time, the patient has developed significant calcaneal valgus deformity with significant pain. Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot. Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening. Risks and benefits of surgery were discussed with the mother. Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months. All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A bump was placed underneath the left buttock. A nonsterile tourniquet was placed on the upper aspect of the left thigh. The extremity was then prepped and draped in a standard surgical fashion. The patient had a previous incision along the calcaneocuboid lateral part of the foot. This was marked and extended proximally through the Achilles tendon. Extremity was wrapped in Esmarch. Tourniquet inflation was noted to be 250 mmHg. Decision was then made to protect the sural nerve. There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way. Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh. Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral. Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally. At this time, we also noted that calcaneocuboid joint appeared to be fused. The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy. This was performed with a saw. After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi. The osteotomy was completed with an osteotome and distracted with the lamina spreader. A tricortical allograft was then shaped and subsequently impacted into this area. Final positioning was checked with multiple views of fluoroscopy. It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly. A pin was subsequently bent and cut short at the level of the skin. The wound was then irrigated with normal saline. The Achilles was repaired with this tie. Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening. A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion. Wound was then closed using #2-0 Vicryl and #4-0 Monocryl. The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case. The wound was clean and dry and dressed with Steri-Strips and Xeroform. Skin was dressed with Xeroform and 4 x 4's. Everything was wrapped with 4 x 4's in sterile Webril. The tourniquet was released after 69 minutes. A short-leg cast was then placed with good return of capillary refill to his toes. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control. The patient to be strict nonweightbearing. We will arrange for her to get a wheelchair. The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control. The patient will need an AFO script at that time. Intraoperative findings are relayed to the parents." }

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

{ "text_length": 4809 }